HomeMy WebLinkAboutWELL-08-2023-202690.TIF CAFAWRA COUNTY Case# WELL-08-2023-202690
r1.e) Public Health Department Subdivision
(...)
Environmental Health DivGovernmentision PIN# 365911558314
Drive,Newton.NC 28658 LOT##
Site Address: 2544 COLEY FISH POND RD, NEWTON NC 28658
Name on Permit: NORMA JEAN HEWITT
Property Size: Acres 6.22
Directions: 16 S to Bethany Ch Rd, 1 left, 1st house on right.
Owner/Authorized Representative Acknowledgement of Permit Receipt
`1. I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
t e property described above.
••(- 1 p/'v s the property owner or authorized representative, I have received the above referenced
",i.Vmit(s)as requested in the application for service EHPR-08-2023-45191,by the following method(s):
JReceived in Person
Facsimile"Transmittal (Return form with signature required)
_ Electronic Image Transmittal/E-mail (Return receipt required)
xAs 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(I5A 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 well permitted.
Permit Issue Date: 08/15/2023
Owner/Authorized Representative Signature,(Q O�-��f.'-/X0A
---7Date
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 wand tto hear from yotPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
/- Old23
ehperm l t 08/15/2023 16:45
i RESIDENT/AL DENT/AL WELL CONSTRUCTION EECQRD
4z J)/ North Carolina Department of Environsnent end Natural Resources-Division of Water Quality
***4.• • ' WELL CONTRACTOR CERTIFICATION# 2 65 " T
1.WELL
RRTA TO y. 4TTRZONES(d
TONYTop Bottom Top Botlom
Wet Contractor(Individual)Name Top Bottom Top Bottom _
DAVIS WELL BORING Top Bottom Top Bottom_
Wall Contractor Company Name
Thickness/
1481 LARRY DAVIS ROAD
T. CA iNG: Depth Diameter Weight Material
Street Address To I Bottom S 1 ,Ft. 24 ' 1.5 Cement_
LAWNDALE NC 28090 Top Bottom Ft.
City or Town State Zip Code Top_^Bottom Ft. .
( 704) 276-3434 _
Area code Phone number 8.V GROUT: Depth Material Method
2.WELL INFORMATION: <3 g, •�y23 120.2/ 96 Top 0 Bottom 20 Ft. Concrete _Truck
WELL CONSTRUCTION PERMITS _ 7 Top Bottom FL
OTHER ASSOCIATED PERMITM(lf applicable) Top Bottom Ft.
SITE WELL ID agr applicable) 9. SCREEN: Depth Diameter Slot Slze Materiel
3.WELL USE(Chac.Applicable Box); Residential Water Supply Top Bottom Ft •In. In.
DATE DRILLED ,• _ '� Top Bottom ,Ft. In, In.
TIME COMPLETED fir
AM Q PM p Top Bottom Ft. in. In.
4.WELLIL?CaAT1�0N: , ` 10.SAND/GRAVEL PACK:
aterial
CITY: �V`C,G-{�t/ COUNTYC Vw63 Top ,1i, Bottom € Ft /t`M Grave].
.5Ai 4 Z ci r )d , ►"/vsd �/Jy�/p_A) Top Bodoni FL
(Street Nan.,Numbers,Cortrnunhy,Subdivision,Lot No.,Penal,Li,Code) Top Bottom Ft.
TOPOGRAPHIC 1 LAND ETTING: (cheer epproprleta box)
❑Slope Malleyat °Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUD DMS OR 3X.XXX XXXKXX DO /
LONGITUDE "Ile DMS OR 7X.X0xx0(xXX ,DD / — ��
Latttude ongitude source: S Ql opographtc map / _
(location of well must be shown on a USGS tope mop endetteched to /
this form it not using GPS) l
lk.J a itt-i A y'zi:iit.1 /4 t 6.1 in"'5,WELL OWNER 0
it C0LleyfrslPoidd _ = --
Street Address E t417o r 1 G 286.511 ----1,--- ___
nY or Town Stato Zip Code
431 /
Area code Phone number —
12. REMARKS:
6.WELL DETAILS: 1
a, TOTAL DEPTH: .. •
b, DOES WELL REPLACE EXISTING WELL? YES* N°0
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: C) FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use'+'If Abov Top of Casln�) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
{ PROVIDED IDTHE WELL OWNER.
d. TOP OF CASING 15 er • FT.Above Land Surface` _ �}
'Top of casing terminated atlor below land surface may require + ' 9 — 23
a variance In accordance with 15A NCAC 2C.0118. srG ATURE O RTIFIED W LL CONTRACTOR DATE
e. YIELD(ppm):-3 METHOD TEST TONY R DAVIS
IL
I. DISINFECTION:TypeWP/tkir Amount_(t o Z PRINTED NAME OF PERSON CONSTRUCTING THE WELL.
Submit within 30 days of completion to: Division of Water Quality. Information Processing, Form GW.la
1617 Mail Service Center, Raleigh, NC 27899.161,Phone:{919)B0T-13300 Rev.2/09