HomeMy WebLinkAboutWELL-2-11-15218.TIF , CATAWBA COUNTY Case # WELL
G Public Health Department
'4,- Subdivision CRESCENT LAND AND TI
Environmental Health Division
d\' 'S PO Box 389, 100 -A Southwest Blvd, Newton, NC 28658 Lot # 277
L842 s° PIN# 461904921433
Applicant/Owner Loretta Czernecki
Site Address: 8994 AZALEA RD, Shen Ford, NC
Property Size: SF 1.45 ACRES
Directions: HWY 16 S - E ON HWY 150 - N ON SHERRILLS FORD RD - R MOLLY BACKBONE - R AZALEA
WELL PERMIT
WATER SUPPLY: Individual Well
SETBACKS:
1. BUILDNG FOUNDATIONS 25 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS - MIN.50 FT.
3. EXISTING & PROPOSED SEPTIC REPAIR AREA - MIN. 50 FT.
4. SEWAGE PUMP SUPPLY LINE 50 FT.
5. UNDERGROUND STORAGE TANKS 100 FT.
6. STREAMS/BROOKS /CREEKS 50 FT.
7. LAKES/PONDS RESERVOIRS 50 FT.
ALL OTHER POSSIBLE SOURCES OF GROUND WATER CONTAMINATION 100 FT.
The well driller must verify all setbacks before drilling the well.
If the well driller is unable to maintain any of the above setbacks,
contact Catawba County Environmental Health at (828) 465 -8270
before drilling the well.
Grouting Depth: Minimum 20 Feet
Casing Height: 12" Above Land Surface
SEE SITE PLAN FOR PERMITTED WELL LOCATION
Robbie Phelps 02/14/2011
ISSUED BY PERMIT ISSUANCE
02/16/11 15:30
CATAWBA COUNTY Permit #
1 Auth -2 -I 1-15220
"t Public Health Department
Name Loretta Czernecki
Environmental Health Division Address 8994 Azalea Rd
v PO Box 389, 100A Southwest Blvd, Newton NC 28658 P11\1# I8 2 sM (828) 465 - 8270 Fax (828) 465 - 8276 TDD (828) 465 - 8200
SITE PLAN
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,gi _ * CATAWBA COUNTY , Case # AUTH -2 -11 -15220
: ci Public Health Depat'tment
Subdivision CRESCENT LAND AND TIN
Environmental Health Division
\v\ 0 ''' PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # 277
\84 s° PIN# 461904921433
Applicant/Owner Loretta Czernecki
Site Address: 8994 AZALEA RD, Sherrills Ford, NC
Property Size: SF 1.45 ACRES
Directions: HWY 16 S - E ON HWY 150 - N ON SHERRILLS FORD RD - R MOLLY BACKBONE - R AZALEA
Owner /Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the
p erty described above.
6
As the property owner or authorized representative, I have received the above referenced permit(s) as
requested in the application for service EHPR -1 -11 -9008 , by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E -mail (Return receipt required)
• 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 an. . r water supply well permitted.
Permit Issue Date: 02/14/2011 C `
0. Owner /Aut orized Representative Si.natur-,401K44.4
y Date / 4 /1
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
acknowledges the conditions and statements above.
02/14/11 13:14
1-p-Ps. Co
-' H CATAWBA COUNTY
U (: ` 'C P 0 Box 389 - Newton, North Carolina 28658 - (828) 465 -8270 - Fax (828) 465 -8276 - TDD (828) 465 -8200
18 42 SM Public Health — Environmental Health Division
February 16, 2011
Mr. Shawn Patterson
Cobble Creek Custom Homes LLC
1658 Maggie St
Catawba, NC 28609
Dear Mr. Patterson:
You came into our office today and picked up a permit for 8994 Azalea Rd. We believe that you were
not given copies of all of the permits there were issued. Enclosed are two copies of the Improvement
Permit, Authorization to Construct and Well Permit that were issued on this property.
I apologize for any inconvenience this may have caused you. If you have any questions please feel free to
contact me at 828 - 465 -8270.
Sincerely,
Julia English
Administrative Assistant II
,402 TNCAR0 4ry
9
Accredited
Healt !1 'O . }
Depart m GREATER
2 "Keeping the Spirit Alive Since 1842!" HICKORY
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03/ 02/"2011 02:49 7048924705 B K WELL DRILLING PAGE 91
sure a (4.> `R-in . ?„,(01:;..i C @.x,
�:�! .'<� R ESIDENTIAL WELL CONSTRUCTION RECORD /-3 /, /
� /i North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION u 3265 -A
1 WELL d)HTRACTOR: g. WAFfR ZONES (op? ) �
Ii11..1
BaL1 Ballet Top s Bottom (. Top Bottom
Well CAntrsctor (Individual) Name Top Bottom 2. S Top w Bottom
B &104 /ell DrIIIJpu Inc. Top Bottom Top_ Bottom_
Well Cio rllractor Company Name
Thickneeel
Struei tddross 7. CASING: Depth ()lamellar Weight Matnrtal
S e dd v1118 Top / Bottom 7 Ft.6 1/8 SDR -2 PVC
Chy or Tbwn 28117 Top Bottom Ft.
S tate Zip Code Top Bottom Ft.
(-1-Q-4.- LE192Afi96
Area code Phone number 8. GROUT. Depth Material Method
2. WELL INFORMATION: Top 0 Bottom 20 Fi, Hole Plug Pour/Hydrate
WELL CONSTRUCTION PERMITlt " // 2- //` /5 7 Top Bottom Ft.
OTHER ASSOCIATED PERMIT/41f applica Top Bottom ,_ Ft.
SITE WE L ID tl(Ir epd;cabre)_ 9. SCREEN: Depth Diameter Blot Size Material
3. WELL USE (Check A pllcabi Boa) Residential Water Supply Zi,"" Top BolYarn 1 fiL in In
DATE ORILLEDI / '// Top Bottom Ft. l '
r
TIME COMPLETED , °' AM D PM �- Top Bottom Ft, in. In.
4. WEL QCATION: 18. SAND /GRAVEL PACK:
�2,9-4 //t 7 ;9- I•- D"PU St=. Matn,1al
crTY:,,
�� b COUNTY /f Top
�r /e /1 /� 0 l! y i 1. e -e / leS,y Top Ft. �_
• Bottom _ - -- — „
(Street time, umoero. Con un Lot M O., P j Top Bottom Ft.
TOPO RAPHIC ! LAND TING' S (cheek eppropnat� tv c�
OSIope! [Valley el ❑Ridge 0Other 11. DRILLING LOG
LATIT E 36 Top B nom Format) n Description
_ ., DMS OR 3x.xxxxx�cxxx DD a / - e. Q � k ,
LONGITUDE 75 °' ° OMS OR 7X.XXXXxxxxX DO 43 �e .. 4-= ...4 0
LetItude/lbnpltude source �iPS (]T opogrephic map fiE.--// � C A V J /
(location of well must be shown on a USGS topo mop andettached to
mis tom, If not using GPS) /
5. LL OWNER , /
,i 6 / C 2,, e_/? - C. /C /
/
Owner lame —
9 11 /1" LC /e /
treet dress - -/
e 'L • / -0.1 • ' 1 `
City or Tpwn State Zip Code /
_ / _
Area code Phone number
12. REMARKS'
S. WELL DETAILS:
a. TOTAL DEPTH :.
b. DOI°iA WELL REPLACE EXISTING WELL7 YES O NO ;L/ µ
1 00 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
C. WATER LEVEL Below Top of Casing - O 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 1 FT. Above Land Surface' �Q 2
'Top of casing laminated at/or below land surface may require . e /� 6 N 1 0 /
ai variance In amordonce with 15A NCAC 2C 0118. SIGNAT OF CERTIFIED WELL C TRACTOR `DATE
2 OrnQ l y
,. Y)E IN (gpm): , METHOD OF TEST 0 - , /--:: �n
. /
L yy-- )t
1. DISFECTION: Type / / 4' Amount 4- 1 ._ � P I TED NAME OF PERSON CONSTRUCTIN THE WELL
Su6Siiiii4tithi 30 days pf .cprPtotJQn t4; 0 ,I1 Water 'In(pnl tion Procta>Irrff19, Form GW -1a
1817 1Gi1111t$ervice CisritQtr, 'Ji t fgh, NC 2 695.7 $,, { oiix : �'f 9)"•ti 7- , . ' :." . ' Rev. 2/09