HomeMy WebLinkAboutWELL-4-11-17369.TIF � CATAWBA COiJNTY Case # WELL-4-11-17369
¢„ G� Public Health Department Subdivision
.� Environmental Health Division
v a� '�' PO Box 389, 100.A Southwest Blvd, Newton, NC 28658 Lot # TR 1
18 Sw P�N# 376403349888
Applicant/Owner HENRY W. SEITZ, JR.
Site Address: 5709 BOLICK RD, Claremont, NC
Property Size: SF 0.629 ACRES
Directions: ROCK BARN ROAD - TURN LEFT ONTO OXFORD SCHOOL RD - TURN RIGHT ONTO RIVER BEND RD - TURN
RIGHT AT BETHEL CHLTRCH ONTO BOLICK RD - 1 ST HOUSE ON RIGHT (BRICK)
WELL CERTIFICA'TE O�' COlVIl'LET'ION
WATER SUPPLY: Well Type:
INSPECTIONS �`
INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR �
INSP-139892 OS/04/2011 EH Well Grouting Annroved Megen McBride �.
INSP-139893 OS/17/2011 EH Well Head Annroved Megen McBride "
INSP-139895 OS/17/2011 EH Well Certificate of Completion Annroved Megen McBride
INSP-139896 OS/OS/201 1 EH Well Record Received Aonroved EH Admin
Ashley Moretz OS/03/2011
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 5/17/2011
AUTHORIZED STATE AGENT APPROVAL DATE
OS/19/2011 08:16
FRO�=1 : h10RETZ IJELL ;: PUf•1P FA;: hd0. : 7�445?13�? f1�.y. �S 2�11 ��: 21Af�1 P1
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' � . ��' �' �'� lA.�SIDF_'NTI,QL vti�EI,Y. CONS�"RUCTIOIV RECOKll
�� „� _ r
"', �.���F Notth Carulina Depsrtment ui �,n��ironmcnt and Natural Rcseurces- Division of �Vater Quali�,
r L
,� Ouy. v�f� �ti�`�
. 'VNEI.,L CONT1tACTOR CERTtFTCATION � 2 5 g 6
1. WELt, CONTRACTOR: P, pISINFECTION: TyD� Amount O�
A� h 1�}� T. M o r e t z g. WATER ZONES (depth):
W elI CeMraCtof (Individual) Name From�� To //(/ Frem 70
—r---- _
M 0 T' P, f 7 �+f p 1] n r 1 1 � j n� Fran1�� To�,� From To
Well Contractor Company Name From 7o From Tc
S"fREET ADpP,ESS 61 5 9 H W Y . � � W e S t 6. CASING Thickness/
Depth D am ler W r,�q � Ivlate ` �
HiCkOt°Y NC 28602 Frem � ro�fQFt.� �,Z,/ �3,
C;ry or Town State Zip Cuc1e From To Ft.
7( �__462- 1322 From Tu F�,
Area cod� Phone number
2. WELL INFoRMAT10N: 7. GROVI": Depth Material i �
w_ // ��� y rn From� To� Ft.
SfTE WELL ID �t(�tapcl�cable) ���1� Frwn _2,CZ� To �� F1._
STATE WELL PEFMI7#(�r�ppliceDie� Frorn To Ft. �
DWQ or OTHER PERMIT #(�F 9pplicable) 8. SCREEN: De Diameter Slm Slze Material
WELL USE (CheckApplicsble Bor,): Residential Water Su 1 FrUm o Ft, in, ��.
/ p � Y From 70
S— �� ! / in. iri.
DATE DRILLED Fr , To F*. �n. ,�,
TIME CoMPLETED_ � � �Q qM,� p�(�
e. SAND/GRAVEI PACK:
3, WELL LOCATION: Depth Size Maierfai
GTY: (11 a.re.,n� �_ COUNTY From e Ft.
A From To
l\
- � I _� /G Fr To Ft.
�Stfwo� Nemt, Numtrcrs, Gom u�niry, $upclvk8 on, L�t No., Parcel. Zlp Codc)
TOFOr,RqpHIC I LAN SETTING: 10. DFILUNG LOG
❑Stope ❑Vallsy let pRldge p0lher From To . FormaGon Descnpt�on
(cAeck aDProD��aie boA) �
L.ATITUDE 3 S� 6� �Y � in desr�es, �/ Q � ��
m�nuczs,seconds or --
LONGITUDE$� 0�.67 �nadccimalfonnat
' L O G
Latitud�llongitude source: �C,PS ❑Topo�aphic map —
(bcatlon of we/l must be shown on a USGS topo map ena
artached fo fhis form e not usinq GPS)
d. WELL OWNER
OWNER'S NAME � ���
STREETADDRESS S O �
C� �e,wt.o�.�- /�/L � .
Ci or Town S1ate Zip Code
( �-
Area code- Phone number
11. RE1�laRKS:
S. WELL DETAILS: � O � �
a. TOTAL DEPTH:
b, pOES WEL� REPLACE EXISTING WEI.L? YES p NO !�'
c. WATER LEVEL BCiov� TOD Of C9si � DO M�R[RV CEFTIF" TLW7 THL `/�61L W��9 CCNL'T2UCTD W ACCGNOAlICE WRN
�� FT. 15A M1CAC 2C, WELL G ON�7RUCTCN STANDARD�, AWD T?IAT A COPY OF TMIS
(Use'+' i( Above Tep of Cas�ng) aEGORD HnE BEEH PROVID'eD 70 TNE wELI OwNER.
d. TOP OF CASING IS �_ F7. Abwe Land Surface' r[J /�
'Tep of casing le,minated aUor below land surface may require SIGNATURE OF C Tl IED E�� CONTRaCTOR �
a variance in accordance with i SA NCAC 2C .Ot 18
. �' /Q �
Q. YIELD (gpm): _� ME7HOD OF TEST A' . �/ ����
PRINTED NAME OF PERS CON TRUCTING THE WELL
Submit 4he original to the Dlvision of 1fVater Qualify within 30 days. Attn: Informadon Mgt.,
1617 Ntail Service Center— Raleigh, NC 27699-1617 Phone No. (919) 731-7015 ext 568. �oRn Gw-ia
Rev. 7105