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HomeMy WebLinkAboutWELL-3-11-15933.TIF � CATAWBA COUNTY Case # WELL-3-I 1-15933 p Public Health Department Subdivision FLYING V ACRES PH 2 � � Environmental Health Division v � '�' PO Box 389, 100.A Southwest Blvd, Newtoq NC 28658 Lot # 14 , r � P�# 362703433059 ApplicantlOwner RMR CONSTRUCTION Site Address: 2578 BROODMARE DR, Maiden, NC Property Size: SF 0.469 ACRES Directions: STARTOWN RD SOUTH / CROSS OVER HWY 32U RT BLACKBURN BRIDGE RD/ LEFT HERTER RD/ LEFT FLYING V ACRES / LOT 14 ON LEFT WEL,I, CERTIF'ICATE OF COlV�PL�T'ION WATER SUPPLY: UVell Type: INSPEC"I'IONS INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR INSP-127102 03/15/2011 EH Well Grouting Annroved Megen McBride INSP-127103 `� - OS/26/2011 ' EH We11 H ead` ..; � ; , Anoroyed , : � Megen 1VIcBride� INSP-127105 OS/26/2011 EH Well Certificate of Completion Aonroved Megen McBride . � . •. INSP-12Z106 ' O.i/21/20l i EH,WeII Record Received -°;. ;° Aoproved .° �: , EH Admin _J Ashley Moretz 03/14/2011 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. Megen McBride 5l26/2011 AUTHORIZED STATE AGENT APPROVAL DATE OS/26/2011 16:28 FROM f`IORETZ WELL a Pump HO. . 7©44621 2? Mar. 21 2011 04: �7Pf1 P73 NE d� s ill' i. 733 0 . (1 RESIDENTIAL WELL(., CONSTRUCTION RECORD % Itil � y:• ' North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 2586 !J 1. WELL CONTRACTOR: f. DISINFECTION: Type RI 8 Amount 1 30 Ashley T. M o r e t z g. WATER ZONES (depth): Wait Contractor (Individual) Name Fran J Q To From To Moret7 Well nri l l i ng From � ()Q To2QZ" From To _ Weil Contractor Company Name From To From To STREET ADDRESS 6159 HWY. 1 0 West 6. CASING: Thickness/ DPW Qp D ter Wa Mtit i a1 (_ City or Town State Zip Code From To Ft. Hickory N� 2$602 From O To [7 Ft. (ma y - ) 1/ 1 ( 744 )-. 462 -1322 Fran To Ft. , Area code- Phone number 2. WELL INFORMATION From To CCy/ /� f� q / p 7. GROUT: Depth Materiel -� ' l J J ! U 30 ,,CI Ft, . A� R 3 =/)iv vti, - , ,,t RE WELL ID fl(I•a policaDte) t�f 3 ��0 - From To Ft. STATE WELL PERS/871RK apettcahte) From _ To Ft _ DWQ or OTHER PERMIT Skit applicable) 8. SCREEN: • Diameter .. Material WELL USE (Cheek Applicable Box): Residential Water Supply CV From To Ft. Mr tn. F . To Ft. In. _ in. DATE DRILLED 3 —_______Val F . To F In, TIME COMPLETED 5. S 0 AM 0 PM [V' 8. SAND/GRAVEL PACK: 3. WELL LACAT }} / / ` Depth Si: e CITY: l kJ j.— COUNTY �,7 -4t/ ✓8. Frani o FL f ,+ From To , Ft. r 1 (4 5 4D T ! / 51 F ommunf y. Subd,wion, Lot No., Panel. Zip Code) TOPOGRAPHIC / LAND STING: 10. DRtLLtNG LOG OStope �P/ �raiey Opal ❑Ridge (Omer From To Formation Descriptbn (chock appropriate coot) te in Ma LATITUDE 5 191 491 /1/ / m'a n ,c,,,,ed• of ' WT 64,v 5x /fi tJ�.� LONGITUDE S ,2 /K. 9 14 in a de°ul Wn°at —-77-72—jr: J Latitude/ion 'rude source: (u I c k . t(jGPS DTopogruph map (tocatbv of wet must be shown ono USGS fopo map and - attached to this forte if not using GPS) 4. WELL. OWNER . OWNER'S NAME gin,' c{ 4" STREET ADDRESS ,,[ S I r 12 ` A We..„ /t/C ,? gt,so City or Town State Zip Code Area code - Phone number 11. REMARKS: 5. WELL DETAILS: sL TOTAL DEPTH: 22 S e b. DOES WELL REPLACE EXISTING WELL? SS TE 0 NO L a WATER LEVEL Below Top of Casing: 5 0 too HEREBY CERTIFY THAT TICS WELL WAS CON M S RUCrrD ACCORDANCE WITH FT, 18A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND MAT A COPY or- THIS (Use '4" if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING IS FT. Abw Lind Surface' / q 'Top d casing temwtoted at/a below land surface may require - n 3 — �l 'l/ a variance in accordance with 15A NCAC 2C .0118. SIGNATURE c CCE ED f-/ W CON DATE e. YIELD (gym): S METHOD Or TEST /g I r /. -1- / ' J PRINTED NAME OF PE(7SON W /fl e- WELL Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., - 1617 Mali Service Center — Raleigh, NC 27699 -1617 Phone No. (919) 733 -7015 ext 568. Form Gw - 13 Rev. 7/05