HomeMy WebLinkAboutWELL-1-11-14808.TIF $ CATAWBA COUNTY Case # WELL-1-11-14808
t, Public Health Department
Q . `� Subdivision
�' " � Environmental Health Division
v�- 9� ''�' PO Box 389, 100-A Southwest Blvd, Newtoq NC 28658 Lot # 17-A
S � PIN# 368702758670
Applicant/Owner LANCE MUSE ��( Qn _' � I� ��'��"
Site Address: 3893 MT BEULAH RD, Sherrills Ford, NC � I �� �
Property Size: SF 3.15 ACRES
Directions: HWY 16 S 12 MILES AND TURE NLEFT ON MT BEULAH RD; 1 MILE BEFORE HWY 150. DRIVE IS 1 MILE ON LEFT
WELI, CE�ZTIFICATE OF COlVIPLET'ION
WATER SUPPLY: VVell Type: �
�
�
INSPECTIONS ^—� �
.._
iNSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR
INSP-117020 02/09/2011 EH Well Grouting Annroved Jason Boyd
INSP-1 17021 03/08/2011 EH Well Head Annroved Jason Boyd
INSP-117023 03/08/20ll EH Well Certificate of Completion Annroved Jason Boyd
INSP-117024 02/09/2011 � EH Well Record Received Annroved Jason Boyd
LEWIS WELL DRILLING 02/08/2011
WELL DRILLER DATE DRILLED
Well permits are valid for 5 years from the date of issuance and are subject to suspension and/or revocation fro 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 Deparhnent
within 30 days upon completion of a well.
Jason Boyd 3/8/2011
AUTHORIZED STATE AGENT APPROVAL DATE
OS/09/2011 12:53
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ES:DENTIAL WELL CONSTRUCTION 'RECORD
, � ,,,,j,-/.. : 6 North Carolina Department of Environment and Natural Resources- Division of Water Quality
° °R°w - WELL CONTRACTOR C TOR CE1RTTFJCATLiON # a "
1. WELL CONTRACTOR: A /J v i_
� / �L 1-0 J Top S Botto ( ill):
/ A P Bottom v< 6 t' Top Bottom
Well Co nnt ractor (Individual NarnQ Top Bottom Top Bottom
//
Lteo. Is' (Individual Je // 7)1/41 �t/19 / �"1 C Top Bottom Top Bottom
welt Co ct Company Name /)
5 � / L 7 1_
CC// (7 / t T 7. Ce ING: Barr D r b al
Street ddress 1 ( / p C) 8ottnmrS. Ft f �Ca
/tt) S Top Ta Bottom Ft
( )T 74' _ ,.,, � o � Smote p C ads Tap Bottom - Ft.
Area code Phone number 8. GROUT: Depth , Method
2. WELL INFORNAT1Oi'S: / �/ 0 _ Top 0 Bottom� Ft. (� C k
WELL CONSTRUCTION PERM Top Bottom Ft.
OTHER ASSOCIATED PERMfT#(pepptcbte) /` /1 // ?,S Top Bottom FL
SITE WELL ID #{r! app! a l 9. SCREEN Depth Diameter Slot Size Lazterial
3. Bt'ELL USE (Chec;c Applicable Box): / ` Residential Water Supply Top Bottom Ft M. in.
DATE DRILLED , ' e— Tap Bottom Ft M. in.
TIME COMPLETED Am 0 PM Top Bottom Ff. in. in.
4. HI/ELL L siT10N: J 1 10. SAND /GRAVEL PACK: :
CITY: et !- 11 / S / Gyi % UN T
Depth
COY U /A..! Top Bottom Ft. Sizra [:? eriai
/ 3 n/ ., � n �) R Top Bottom Ft
(Street Name, Numbers, Community, Subaltrisian, Lot No.. Parcel, Zp Cate) Top Bottom Ft
TOPOGRAPHIC / LAND SE I t !NG: (th5cY appropriate bo )
lope D Valley 0 Flat o Ridge D Other 11. DRILLING LOG
LATITUDE 36 Top Bottom Formation Description " DMS OR 3X.XXxXXxxxX DD /
LONGITUDE 75 ° ° DMS OR 7X.Xxxxxxx00X DO -73 1
Latitude/Iongitude source: CEPS Dropographic map I < !` d
(location of well must be shown on a USGS topo map endatacted re I . /
this form if not using GPS) 1I ma
_-- ,S__i
S. WELLOtRTIER ndC... "re _ ls _ juju& ACJ
Owner Name /
3893 gezihd, /ed
Stree +Address /
City or Town Staff, Z ip Cade /
( ) /
Area code Phone number
12. REMARKS:
3. WELL DETAILS:
a. TOTAL. DEPTH:
b. DOES E9fELL REPLACE EYJSTJG WELL? YES Nt
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c. WATER LEVEL Belocr Top of Casing: FT. ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION
(Use ° +' if Above To of Casing) STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDFD THE LL 0 .4' R. , /
-
d. TOP OF CASING IS FT. Above Land Surface" '
'Top of casing terminated at/or below land surface may require i � I / f , , - 57/
a variance in a •e•rdance with 15A NCAC 2C . 0118 SIG'' • TU `' O l' WELL. n . s RA OR DATE
e. YIELD (span): I P : OD OF TEST ! � r / Ali C� , e �r C.�
f. DIS1 ?FECTION: Type I`IS A°nau / / nt / PRIPII 0 NAME OF PU - SON CONSTRUCTING THE WELL
i
Submdg c oAgii e to tths E:Div o5sori! of trlia r Qa!s96ty r',t h't 3 dsy z. Gib: infor ton Egt., Form GW - a
1697 Mall S rvice Winter- RaIsigh, NC 2768 -9617 Phone No. (OMMM 8 74300 Rev. 11/08