HomeMy WebLinkAboutWELL-11-09-2465.TIF
~A C Case # EHPR-1 1-09-2475
nG CATAWBA COUNTY
Subdivision
Q G Public Health Department
Environmental Health Division Section/Bl/Ph/Lot#
v Y PO Box 389, 100A Southwest Blvd, Newton NC 28658 PIN# II q
1$ t~2 sra (828) 465-8270 Fax (828) 465-8276 'fDD (828) 465-8200
Applicant/Owner Kell Nash
Site Address: 2262 Hewitt Rd, Claremont
Property 15 a
Directions:
WELL PERMIT
Proposed use: Private ® Public ❑ Semi-Public ❑ Other ' S
GROUTING DEPTH: MINIMUM 20 FEET
SETBACKS:
L BUILDING FOUNDATIONS 25 FT. 5. UNDERGROUND STORAGE TANKS 100 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 50 FT. 6. STREAMS/BROOKS/CREEKS 50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA MIN. 50 FT. 7. LAKES/PONDS RESERVOIRS 50 FT
4. SEWAGE PUMP SUPPLY LINE 50 FT.
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all separations are adhered to before drilling the well.
If the well driller is unable to maintain any of the above separations, contact the Health Department at (828) 465-8270 before drilling the well.
SEE SITE PLAN F~OR/~PERMITTED WELL LOCATION
x' ' U / 11-5-09
ISSUED BY PERMIT ISSUANCE DATE
CUSTO SIGNATURE DATE
WELL INSPECTION:
GROUTED DEPTH: 20' ❑ DATE: INITIALS:
APPROVED CASING: PVC ❑ STEEL ❑ DATE: INITIALS:
CASING HEIGHT 12' ABOVE LAND SURFACE ❑ DATE: INITIALS:
WELL COMPLETION REPORT RECEIVED ❑ DATE: INITIALS:
WELL HEAD APPROVED ❑ DATE: INITIALS:
WATER SAMPLES TAKEN: BA ❑ IO ❑ N/N ❑ DATE: INITIALS:
WELL DRILLER DATE DRILLED
Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation for non-compliance with
appropriate state and local rules and regulations, or if false information was given in order to obtain a permit. Wells shall be constructed in
accordance with all state and local regulations and rules. The Well Completion Report must be submitted to the Health Department within 30
days upon completion of a well.
CERTIFICATE OF COMPLETION
AUTHORIZED STATE AGENT APPROVAL DATE
$A C CATAWBA COUNTY Case # EHPR-1 1-09-2475
Public Health Department Subdivision
Environmental Health Division Section/Bl/Ph/LoO
J PO Box 389, 100A Southwest Blvd, Newton NC 28658 PIN#
(828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200
1g42 sM
Applicant/Owner Kell Nash
Site Address: 2262 Hewitt Rd, Claremont
Property Size: 15 a
Directions:
Improvement Permit ❑ Authorization to Construct ❑ Well Permit
SITE PLAN
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System components represent approximate contours only. The contractor must flag the system prior to beginning the installation to ensure that proper grade is maintained. Do not
install system under wet conditions. This permit is subject to revocation if the site plan or site conditions are altered.
✓4 A'- dl~~ 11-5-09
AUTHORIZED STATE AGENTDATE
EHPR-11-09-2475
TRACKING INFORMATION
Date Calls
11-3-09 1st Contact - Discussion Only
11-3-09 Site Ready to be Flagged
11-3-09 Site Flagged
11-3-09 Site Ready to be Evaluated
11-3-09 Site Evaluated
11-3-09 Approved for Issuance
Other
Date Comments/Field Notes
° RESIDEA7LIL WELL CONSTRUCTION RECORD
wataQuality
North Carolina Department of Eoviroament and Natwal Resources- Division of
~ WELL CONTRACTOR CERTIFICATION # NCWC 2l SO-A
1. WELL CONTRACTOR: g. WATER ZORES (depth):
Gary d Justice Tap Bottom Top -Bottom
Well ConlraMn► (individual) Name Top I `(C gottom (t{ S Top _ Bottom
Justice well dtillina = Top 1 70 Bottom-L9--0- Top -Bottom
Well Contractor Company Name Thlcknessl
3845 US 70 west 7. CASING: Depth Diameter Weight Material
Street Address Top Bottom FL
Marion n x 2875 Top U Bottom- Ftsa=IG3- _`~1)-e-
City or Town State Zip Code ToP Bottom % Ft 1• i ~ Lack S1ee~
( 828 724454$
Area code Phone number 8. GROUT: Depth Material Method
2. WELL INFORMATION: = Top Bottom FL
WELL CONSTRUCTION PERMiTN Tap Q Bottom 10 Ft. 7I~n; fr (iC,J PiJAV,9e
OTHER ASSOCIATED PERM ITif(iFapplicede) Top Bottom Ft _
.
SITE WELL ID*(•ifappffcable) S. SCREEN: Depth Diameter SW. Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply O Top Bottom FL in. in.
DATE DRILLED Il" Zug ToP Bottom FL in. m-
Top Bottom FL in. in.
TIME COMPLETED AAA ❑ PM 0
10. SANDJGRAVEL PACK:
4. WELL LOCATION: Depth Size Material
CITY lti C LC n l COUNTY 1 - Top Bottom FL -
! 4 r Pi0o.i 7 Top Bottom FL -
(Srreet Name. Numbers, m-murny, Slmbdwtaion, Let No.. Panxl, Zip Coda) Top Bottom FL _
TOPOGRAPHIC I LAND SETTING: tclerkappiopnate box) 11. DRILLING LOG
❑Slape pValley ❑Flat cRidge DOther Top Bottom FonmhaUOn Description
LATITUDE 4635 °_~L' 5 ? DMS OR 3x-XCOOOO= DD f
LONGITUDE 34 Ifs °jaL' 76 7 DMS OR 7X.70aMV=X DD ! r
Latitude/Iongitude sour-„e: opographlc map f
(location of well must be shown on a USGS topo mar andattached to D ! O~~~ i
this form if not using GPS)
f
5. WELL OWNER
~3.1L' ~4SL - 1
Ownef Name / f
Street Address
ad j-Wk1j a Q, t* c ~ G~ 1 -NOV ri ~nnn
City~orTawn State Zip Code /
~I er !
Area code P ne number =WBACOUNlY
12. REMARKS: ENVIRONMENTAL HEALTH
6. WELL DETAILS: c
a. TOTAL. DEPTH: O
b. DOES WELL REPLACE EXISTING WELLS YES O NO I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing: Jc r FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use'+" if Above Top of Casing) STANDARDS, AND THATA COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER-
d. TOP OF CASING IS t FT. Above Land Surface'
-
'Top of casing terminated r low land surface may require
a variance in accordance with 15A NCAC 2C .0118. LL CONTRA(;TOR DATE
e- YIELD (gpm):METHOD OF TEST H I Ga D- justice
f. DISINFEC111ON:Type Amount PRINTED NAME OF PERSON CONSTRUCTIOG THE WELL
Submit Within 30 days of completion to: Division of Water Quality - Information Processing, FR~ vrWAa
1617 Mall Service Center, Raleigh, NC 276991161, Phone : (919) 807-6300
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