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HomeMy WebLinkAboutWELL-05-2023-195608.TIF t 1 �=+ CATAWBA COUNTY ,u.>�., ..__ • Subdivision Public Health Department , ,'�,, Environmental Health Division PlN## 461602593350 PO Box 389,25 Government Drive,Newlin,Ni" 28658 LOT# 2 Site Address: 8527 FIELDSTONE DR, TERRELL NC 28682 Name on Permit: LUX CUSTOM HOMES LLC Property Size: Acres 1.048 Directions: NC 150, right onto Kiser Island Rd, right onto Fieldstone Dr, left onto Beechwood Trail Owner/Authorized Representative Acknowledgement of Permit Receipt t( VP)] certify that I am the owner or authorized agent(owner's authorization required)representing the owner of the property described above. iUP, As the property owner or authorized representative, I have received the above referenced permit(s)as requested in the application for service RBPR-04-2023-44056, by the following method(s): Received in Person Facsimile Transmittal(Return form with signature required) Electronic Image Transmittal/ E-mail (Return receipt required) Y. VP) As the property owner or authorized representative I have reviewed and understand the specific conditions of the permit issued, and further understand that all applicable regulatory requirements specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A.1900), and/or Well Construction Standards(15A NCAC 2C .0100), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply w l permitted. Permit Issue Date: 05/12/2023 Owner/Authorized Representative Signature r _-- ':Date Oct/51 2 3 Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) Signature Date/Time Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey aft http://www.surveymonkey.com/s/EH CusttomerService �k ehpennit 05/15/2023 08:36 ee41,) WPDT Screening Report Area of Interest (AOI) Information i Area : 3,134,508.67 ft2 May 15 2023 16:22:58 Eastern Daylight Time illk-- ---,.. -----N. a 0 \ Y J ' C O 9 'lir IIPA :._ li‘rL' -----.- 1 112( _____,,, i J------ '. - . ....... Nr, , . ......, <,, t -U -rill eon-r ,•a .______ ----.47.. r _ i . • 1 ff7%, """. 1r 4 ip 1. t�rr, --__ 802fr ~`� I L . 1:4,514 Parcels(Polygon,)-Parcels Projected Route U 003 006 0.12:r. i 1 % 5 '-• •i ti ' i C County Boundary — Other State Agency Route 0 0.05 0.1 G.2 km Non-System Roads — Secondary Poole -- Federal Route Primary Roads __ Non-System — Interstate EA Cluo,,,,Ry MaoC„uror ew, ..n, Cowl./ sir of N,nr,Ce,ca,u DOT p'{1;,v.kosittap, fAranrdl Evi KM. Gam, S.A.G.ph Other System Roads — US Route oaoT hniriooaa•s2 IXET iASA,users.EPA.NPS US Gene..o am USDA 40o0T G'.S U-,! Su,..s Es+.Aid.OS.USGS NGA.IA&A — Ramps,Rest Areas,Non.Mainbne — NC Route 8527 Fieldstone Dr,Terrell All North Carolina Department of Environmental Quality (NCDEQ)GIS data is expressly provided"AS IS"and"WITH ALL FAULTS",The NCDEQ makes no warranty of any kind,express or implied,concerning this information, including but not limited to any warranties of merchantability or witness for any particular purpose.The NCDEQ assumes no responsibility or legal liability concerning the Data's accuracy,reliability,completeness,timeliness,or usefulness.The data is not intended to constitute advice nor is it to be used as a substitute for specific advice from a professional.Users should not act (or refrain from acting)based upon information in the Data without independently verifying the Information and obtaining any necessary professional advice.Users are solely responsible for ensuring the accuracy, currency and other qualities of any products derived from or in connection with the NCDEQ's Data.The Data is collected from various sources and may be modified over time without notice to improve spatial and attribute accuracy. The NCDEQ disclaims responsibility for the spatial accuracy and attribution of GIS features and makes no warranty concerning same. WELL CONSTRUCTION RECORD(GW-1 Print Folly) For Internal Use Only: 1.Well Contractor Information: Robert Teague 14.WATER_ZONES Well Contractor Name FROM TO DESCRIPTION 2857-A a 3 eft. a c & a Ciie: p.* NC Well Contractor Certification Number 4 IJ cit. 411 on I S p/v, B &K Well Drilling Inc 15.OUTER CASING(for multi-caned wells)OR LINER(if applicable) FROM TO♦� DIAMETER THICKNESS 1C MATERIAL Company Name 0 it. /Y/ft 6 1/8 In, SDR-21 PVC �!� 16.INNER CASING OR TUBING(geothermal clmed4asp) 2.Well Construction Permit ttel ittI 3-/q(3 C _FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) H. ft, in. 3.Well Use(check well use): R. ft. in. Water Supply Well: 17.SCREEN QAgriCUltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL FROM ft. ft. in. DGeothermal(Heating/Cooling Supply) laResidential Water Supply(single) n• ft. in, QlndustriaVCommercial ()Residential Water Supply(shared) ',irrigation 18.GROUT FROM TO MATERIAL ESIPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft. ft. CiMonitoring Recovery ft. it Injection Well: °Aquifer Recharge ()Groundwater Rcmcdiation ft. ft. Aquifer Storage and Recovery Salinity Barrier 19,SAND/GRAVEL PACK(if applicable) FROM TO MATERIAL. EMPLACEMENT METHOD []Aquifer Test C3Stormwater Drainage rt. ft. .._ Experimental Technology 0 Subsidence Control ft. ft. OGeothermal(Closed Loop) EITracer 20.DRILLING LOG(attach additional'beets if necessary) Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hard ,oWVrack type.grain dtt.etc.) Q C� ff. j ft. d (A 4.Date Well(s)Completed:!-) i - Well ID# j LI 1 f. !3 0 `ft. �Cr1j 4 ne Jf� 1 uc.. rc,,,,l c- 5a.Well Location: 3 n "`fit,$( S ft• }Abort) S 4�-r y r-s�L tie- I-UX I,Sa 6.))a-1j S L L 6- n. rt. 1 Facility/Owner Name i Facility ID*(if applicable) ft• ft. © n 5? ? (-. i't-16--74(sprat_ Or /?r- -Cl1 1 ft. n, Physical Address,City,and Zip ft, ft. kCNA.A.) 21.REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l (if well field,one let/long is sufficient) 22.Certification: N W /- 4717--- 1- /.' - 3 6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well C ctor Date By signing this form,1 hereby t'erliifi'that the ssr//lst was(were)constructed in accordance 7.Is this a repair to an existing well: 1JYes or No with 15.4 NCAC 02C.0100 or ISA.NCAC 02C.0200 Well Construction Standards and that a If this is a repair.fill out known well construction in(ormaann an trydain the nosure y(the copy of this record has been provided to the well owner. repair under 821 remarks section or on the back of this form. 23.Site diagram or additional well details: 8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. drilled:_ �-.+ SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: !rj For multiple wells list all depths ifdierent(example-3It200 and 2@U00'( (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: 10.Static water level below top of casing:40 if water level is above casing.use"+-" (ft.) Division of Water Resources,Information Processing Unit, 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6 1/8 On.) 24b. For Injection%Yells: In addition to sending the form to the address in 24a 12.Well construction method: Air Rotary above, also submit one copy of this form within 30 days of completion of well (i.e.auger,rotary,cable,direct push etc.) construction to the following: FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh.NC 27699-1636 13a.Yield(gpm) gs V Method of test: Air Flow 24c.For Water Supply&Injection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: Amount:Chloe Tabs t t/z Lbs completion of well construction to the county health department of the county where constructed. Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016