HomeMy WebLinkAboutWELL-2-11-15498.TIF �pA CATAWBA COUNTY Case #
y � G Public Health Department W�LL,-2-I 1-1�498
ti ? Subdivision
-, Environmental Flealth Division CLLENS WAY
v �a � PO Box 389, 100-A Southwest [31vd, Newton, NC 28658 Lol # � 5' �
!8 2 sw PIN# 266801396617
Applicantl0wner PHILLIP MOOSE �3�' �
Site Address: 2365 BAYLEIGH DR, Vale, NC ��� �_ 1 �
Property Size: SF 0.479 ACRES
Directions: HWY ]0 W/ RT PROVIDENCE CH RD/ LT OLD SI-II�LI3Y RD/ R"f JACOBS FORK RIVER RD/ R"1' INTO GLLENS WAY
ON BAYLGIGH DR / CORNER OF BAYLEIGI-I'I' DR & DO[3BIN CT
WELL CERTIFICATE OF COMPLETION
WATER SUPPLY: Well Type:
INSPECTIONS
INSPECTION# COMPLETED INSPECTION TYPE STATUS IIVSPECTOR
INSP-1231 12 03/14/201 1 EH Well Grouting Aanroved Megen McBride
INSP-123113 03/23/201 l EH Well Head Annroved Megen McBride
INSP-1231 15 03/23/201 l EH Well Certificate of Completion Aoproved Megen McBride
INSP-1231 16 03/15/2011 EH Well Record Received Anproved EH Admin
Justice Well Drilling 03/14/2011
WELL DRILLER DATG 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 infonnation 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.
Megen McBride 3/23/2011
AUTHORIZBD STATG AGENT APPROVAL DA"I'E
03/24/2011 13:13
, CATAWBA COUNTY Case # WELL -2 -11 -15498
G Public Health Department
E f Environmental Health Division Subdivision ELLENS WAY
: v 1 * " PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # 15
18.2 s,. PIN# 266801396617
ApplicantlOwner CMH HOMES INC
Site Address: 2365 BAYLEIGH DR, Vale, NC
Property Size: SF 0.479 ACRES
Directions: HWY 10 W/ RT PROVIDENCE CH RD/ LT OLD SHELBY RD/ RT JACOBS FORK RIVER RD/ RT INTO ELLENS WAY
ON BAYLEIGH DR / CORNER OF BAYLEIGHT DR & DOBBIN CT
WELL PERMIT
WATER SUPPLY: Individual Well
SETBACKS:
1. BUILDNG FOUNDATIONS 25 FT.
2. EXISTING & PROPOSED SEPTIC SYSTEMS - M1N.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
Megen McBride 02/22/2011
ISSUED BY PERMIT ISSUANCE
02/23/11 14:31
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is RESIDENTIAL WELL CONSTRUCTION RECORD
a , North Carolina Department of Environment and Natural Resources- Division of Water Quality
u_ WELL CONTRACTOR CERTIFICATION # 2150
1. WELL CONTRACTOR: g. WATER ZONES (depth):
Gary D. Justice Tap Bottom Top Bottom
C
Well Contractor (Individual) Name Top t' L Bottom S Top Bottom
Justice Well Drillino. Inc. Top a 70 Bottom cs Top Bottom
Well Contractor Company Name
Thickness/
3845 US Hwy. 70 West 7. CASING: Depth Diameter Weight Material
Street Address Top Bottom Ft.
Marion NC 28752 Top 0 Bottom 6? Ft. 61/5/ sv* 2/ vc
City or Town State Zip Code Top G S Bottom 70 Ft. C 11 • /ST 3l siee
( 828) 724 -4548
Area code Phone number C/ 8. GROUT: Depth Material Method
2. WELL INFORMATION: \ J CI I - AI ') 5L/'7 D Tap (7 Bottom 3 Et. & 1t, PL Peort/
WELL CONSTRUCTION PERMITi1.1_fxL2 1-5 1 C 7 Top 3 Bottom ,20 Ft. ( C- rf::i/ Pu,,,ae0l
OTHER ASSOCIATED PERMIT #(if applicable) Top Bottom Ft.
SITE WELL ID #(Aappk blo) 9. SCREEN: Depth Diameter Slot Size Material
3. WELL USE (Check Applicable Box): Residential Water Supply I=I Top Bottom Ft. in. in.
DATE DRILLED 7/ I'f/ 11 Top Bottom Ft. in. in
/ III Top Bottom Ft. in. in.
TIME COMPLETED AM [ PM ❑
4. WELL LOCATION: 10. SAND /GRAVEL PACK:
f Depth Size Material
CITY: / J Ell 1 uu A L , I <' NC. COUNTY l Lit L; k 1 Top Bottom Ft.
J to c h 0 o /3 Z!f Cn.s hJcy} Top Bottom Ft.
(Street Name, Nurf bens, community J ! fhmunity ubdivisio Lot No., Parcel, Zip Code) Top Bottom Ft.
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope [Valley 'tat ❑Ridge ❑Other 11. DRILLING LOG
Top Bottom Formation Description
LATITUDE IS S5 . 37' i 7 P1 " DMS OR 3X.XX�OtXooc( DD /
..,Q8 LONGITUDE ES g) "g pi " DMS OR 7X.XXXXXX)(X DD / • L
Latitude /longitude source: PS [jfopographic map / D ( M
(location of well must be shown on a USG.S topc map andattached to / / ✓ T\
this form if not using CPS) w (Y _ �'k -�
1
5. WELL OWNER /
PI - I1 ltAP 6 mLiSSA rnooSti. /
Owner Name /
.3(45 e" 1eigi -1 r) /
Street Address /
volt NC. .28(ot 8 /
City or Town State Zip Code /
(2z8) a3y -t(4)47 /
Area code Phone number
12. REMARKS:
6. WELL DETAILS:
a. TOTAL DEPTH: 7;0_ /
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C�
I DO 1 EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN
c WATER LEVEL Below Top of Casing: C FT. ACC - DANCE WITH 15A NCAC 2C. WELL CONSTRUCTION
9 !�
ST. ' *ARDS, AND THAT COPY OF THIS RECORD HAS BEEN
(Use ° +" if Above Top of Casing)
PRr) DED TO THE LL OW+ ER.
d. TOP OF CASING IS ( FT. Above Land Surface' 6
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A NCAC 2C .0118. SI a 'A i " E OF L.ER I IED WELL CONTRACTOR DAT
e. YIELD (gpm): Co 6 METHOD OF TEST A;r Gary D. Justice
f. DISINFECTION: Type chlorine Amount C 0 7_ PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Z'd 8175b- 17ZL-8Z8 eoi }snr e8b:60 L L 9l. JOW