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Home My WebLink AboutWELL-3-10-5100.TIF �gA CATAWBA COUNTY Case # WELL -3 -10 -5100 c, P ublic Health Department /` Subdivision MOUNTAIN CREEK RIDGE ('` ' Environmental Health Division u " PO Box 389, 100 -A Southwest Blvd, Newton, NC 28658 Lot # 22 /8 2 5M PIN# 369803206970 Applicant/Owner TRACIE FORREST d- L --11) Site Address: 3212 CREEK BEND CT, Sherrills Ford, NC L /fink c Property Size: SF 0.839 ACRES Directions: HWY 16 S, LEFT MT BEULAH, AT STOP SIGN RIGHT ON LITTLE MOUNTAIN RD, LEFT MOUNTAIN CREEK RIDGE, 2ND LEFT ONTO CREEK BEND, HOUSE ON RIGHT IN CUL DE SAC 3212 ON MAILBOX WELL CERTIFICATE OF COMPLETION WATER SUPPLY: Well Type: Individual Well INSPECTIONS INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR ` ` INSP -35296 03/15/2010 EH Well Grouting Approved Robbie Phelps W PERMIT FOR WELL REPAIR 17 INSP -35297 03/15/2010 EH Well Head Approved Robbie Phelps INSP -35305 03/21/2011 EH Well Certificate of Completion Approved Robbie Phelps INSP -41369 03/21/2011 EH Well Record Received Approved EH Admin Advance Well Drilling Advance Well Drilling 05/10/2006 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 Dept latent within 30 days upon completion of a well. Robbie Phelps 3/21/2011 AUTHORIZED STATE AGENT APPROVAL DATE 03/21/2011 13:31 Case # U CATAWBA COUNTY EHPR-2-10-4058 Public Health Department Subdivision Mountain Creek Ridge ;a i7► Environmental Health Division Section/BI/Ph/Lot# 22 PO Box 389, 100A Southwest Blvd, Newton NC 28658 PIN# 1 g 42 sm (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 Y y f, - 3 !i b I DD Applicant/Owner Tracie Forrest Site Address: 3212 Creek Bend Property Size: 0.839 Directions: WELL PERMIT Poo Proposed use: Private ® Public ❑ Semi-Public ❑ Other SG GROUTING DEPTH: MINIMUM 20 FEET SETBACKS: 1. 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 FOR PERMITTED WELL LOCATION U 3-3-10 ISSUED B PERMIT ISSUANCE DATE CUSTOMER S GNATURE DATE WELL INSPECTION: GROUTED DEPTH: 20' ❑ DATE: 3-f5-10 INITIALS: j/z P APPROVED CASING: PVC ❑ STEEL ❑ DATE: INITIALS: 7 CASING HEIGHT 12' ABOVE LAND SURFACE ❑ DATE: INITIALS: WELL COMPLETION REPORT RECEIVED ❑ DATE: INITIALS: n v J WELL HEAD APPROVED F-1 DATE: I-ice INITIALS: 11asoycf ~ur WATER SAMPLES TAKEN: BA ❑ IO ❑ N/N ❑ DATE: INITIALS: U vvf- l l r1c,A~ r ~l c~1 ti h L.-2_ 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 g,A C CATAWBA COUNTY Case # EHPR-2-10-4058 Public Health Department Subdivision Environmental Health Division Section/Bl/Ph/Lot# PO Box 389, 100A Southwest Blvd, Newton NC 28658 PIN# (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 Ig 42 SSA Applicant/Owner Tracie Forrest Site Address: Property Size: Directions: Improvement Per uthorization to Construct ❑ Well Permit SITE PLAN ~r L Or It& h L' err VV 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. Y kL 3 - ~ O AUTHORIZED STATE AGENT DATE An a 3. �� MFt �� Y r r °_ - (l RESIDENTIAL WELL CONSTRUCTION RECORD �,� .�'( 5'• 1i jc7 G - , , 1 , �� North Carolina Department of Environment and Natural Resources Division of Water Quality WELL CONTRACTOR CERTIFICATION # 3 - 3 r, 1. WELL CONTRACTOR: f. DISINFECTION: Type i i T ' \ Amount c 't \:. /\ •i C am, g. WATER ZONES (depth): Well Contractor (Individual) Name From n From To P \ $: 1..\_1 0.,TCC.Ct �; \�e \\ _ 1�f , 1 \, . Ll._.L, From o�j> From To Well Contractor Company Name - From To From To r. ,) t ` ` ,� 6. CASING: - i 5 I Thickness! STREET ADDRESS ` - 1 ..)..0, u!..3 `~ `: `�'` Depth . Diameter Weight Material ill ,A L CY) From To CO Li Ft. y '' i} (O:- City or Town Lk State Zip Code From To Ft. " :� -:), ` --- i t t -? OC., From To Ft. Area code- Phone number 7. GROUT: Depth Material Method 2. WELL INFORMATION: , r L`t From To Ft. SITE WELL ID #(ir applicable) From 0 ,To (, 0 Ft. Cc7 •■Cr/f/14 j c. -$4 STATE WELL PERMIT#(ifapplicable) From To Ft. DWQ or OTHER PERMIT #(if applicable) 8. SCREEN: Depth Dia, eter Slot Size Material From To in. in. WELL USE (Check Applicable Box): Residential Water Supply p From To t_ in. in. DATE DRILLED i\ - / / / Pr / From To Ft l . in. TIME COMPLETED 1 `- c7 ' AM D PM EW 9. SANDIGRAVEL PACK: 3. WELL LOCATION: t /� ( Depth S Material To CITY: S Itisst , ( s i 0 p hk COUNTY CAA i t'' JG`- From To i F t. �.� 11 Q. R-z C. F J'Z" ,�- COL'' � -2 $ From To Ft (Street Name, Numbers. Community, Subdivision, Lot No., Parcel. Zip Code) TOPOGRAPHIC / LAND SING: 10. DRILLING LOG Q Slope D Valley 0 Flat &Ridge ❑ Other From To Formation Description (Check appropriate box) May be in degrees, i LATITUDE " _ minutes, seconds or my LONGITUDE `--_ -- ' in a decimal format Latitude /longitude source: DGPS ❑Topographic map 11' (location of well must be shown on a USGS topo map and M attached to this form if not using GPS) 4. WELL OWNER � OWNER'S NAME_ 5C''O k- `� ° Y ='G-G FO vc.15 / STREET ADDRESS 3 2 t,. C'- 'lZ'e 6'e'i'. � � IS F-C4 , -C- • 9 c((r - 71' City or Town ) State Zip Code ('--/'O4)- Li5 5o Area code - Phone number I1. REMARKS: , 5. WELL DETAILS: ) • k ..1 ' r r� 1 . i n{ 4/ , iA 0 Lk a. TOTAL DEPTH: t,/1/4.)-7.A-1 i l 4-- k ' (i-tA t., t It 1,• -te G•; "i b. DOES WELL REPLA E EXISTING WELL? YES NOD cv, /rCai..r, (.vl3,f1-' i ✓u. 9-r;rk (0 . :ti �}, f 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE VON c. WATER LEVEL Below Top of Casing: Uv /0 FT. 15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS (Use `+" if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING IS $ rr i-� V FT. Above Land Surface' 7 ��.% — V-. . °Top of casing terminated at/or below land surface may require SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE a variance in accordance with 15A NCAC 2C .0118 _ ___, 1 C e- YIELD (gPm) NJ/ A METHOD OF TEST - ` + PRINTED NAME OF PERSON CONSTRUCTING THE WELL Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt., Form GW - 1a 1 617 Mail Service Center — Raleigh, NC 27699 -1617 Phone No. (919) 733-7015 ext 568. Rev. 7/05