HomeMy WebLinkAboutWELL-5-10-7396.TIF ,g , • • CATAWBA COUNTY Case # WELL - - 10 - 7396
T
Public Health Department
'1' � 2 Subdivision
Environmental Health Division
" n 0 .1 PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot #
,w PIN# 370109252297
Applicant/Owner ROBERT DALE LUTZ ,IV-
Site Address: 4794 BOWMAN RD, Hickory, NC v OR- l0 53) 7
Property Size: SF 1.09 ACRES
Directions: MT VIEW EXIT 42 FROM 40, TURN LEFT ON HWY 127 TOWARD HICKORY. TAKE 1ST RDON RIGHT TO JOHN
BOWMAN RD. GO TO STOP SIGN TURN RIGHT WILL BE 4TH HOUSE ON RIGHT. BRICK HOUSE GREEN
SHUTTERS.
WELL CERTIFICATE OF COMPLETION
WATER SUPPLY: Well Type: Individual Well
INSPECTIONS
INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR
INSP -55088 06/16/2010 EH Well Grouting Approved Susan Bumgarner
INSP -55089 02/07/201] EH Well Head Approved Susan Bumgarner
INSP -55091 03/22/2011 EH Well Certificate of Completion Approved Susan Bumgarner
INSP -55092 03/21/2011 EH Well Record Received Approved EH Admin
Ashley Moretz 05/21/2010
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. Welts 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.
Susan Bumgarner 3/22/2011
AUTHORIZED STATE AGENT APPROVAL DATE
03/22/2011 15:00
FROM : MORETZ WELL 2. PUMP FAX NO. : 7044621322 Mar. 21 2011 04:36PM P1 •
,ate/ � �� .
i r . " RESIDENTIAL WELL CONSTRUCTION RECORD
v � 1 1:.'"I ,<.
S North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2586
1. WELL CONTRACTOR: f. DISINFECTION: Type / //r' Amount 7 Q Z
Ashley T. M o r e t z g. WATER ZONES (depth):
Well Contractor (Individual) Name From2 p To 160 From , To
MQretz WPM lri 11in0 From To From To
Well Contractor Company Name From To From To
STREET ADDRESS 6159 HWY. 1 0 West 6. CASING: Thickness[
Depth a ter v'`e. Ma 'k
Hickory N C 28602 From 0 To_i Ft, =�UK�� - Y�
City or Town State Zip Code From To Ft.
( IL.)-- 462 -J 322 From To _ Ft.
Area code- Phone number
Ft. G 7. GROUT: Depth Material Method t
2. WELL INFORMATION: Q
Welt- 9 -i 17 To 2/ e...mil
SfTE WELL ID *If applicable) ��' / v From From To Ft. � _
STATE WELL PERM1T8pfapplteabte) -- _ From To Ft.
DWQ or OTHER PERMIT #(if applicable) 8. SCREEN: De. • Diameter S • ize Material
WELL USE (Check Applicable Box) • Residential Water Supply From To Ft. in.
Fro To in. In.
DATE DRILLED 5 g Q -1 Q F F. To t, In.
1
TIME COMPLETED • 3o AM O pm b/
9. SANDIGRAVEL PACK:
3. WELL LOC/tiTION: Depth Size Material
�L r / / _ From _ e Ft.
CITY: (� n 9/ COUNTY 04.0.. From To Ft,
4 Fr To
(SeeeI ame. umbers, Community, Subdivision, L No.. Parcel. Zip C .e)
TOPOGRAPHIC / LAND SETT G: 10. DRILLING LOG
OSlope ❑Valley °Flat VIdge ❑Other From To Formation Description
(check appropriate box)
Q [vl lx in dcyrccs, _ ; r r
LATITUDE 3 Wo Sy-S /r mn utes, seconds er 441:111110 �� ' 7
/ h 7 9 l,/Pi in a decimal 1017n3(
LONGITUDE L, V � / 3.0. +z y 1 „. ttoLA
Latitude/longitude source: VPS °Topographic man
—
(location of well must be shown on a USGS topo map snd
attached ro this form if not using GPS)
4. WELL OWNER / �
OWNER'S NAME `Q ber DJ _ (4--i-
1. - _{
z_
STREET ADpDRESS ,4 oivAa.. A •
/7 C-I rY L ,2 Ni612
City or Town State Zip Code
(.___.)-
Area code - Phone number
11. REA1ARi{S:
5. WELL DETAILS: ��� f
3. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES NO >gr
i DO HEREe• ccttTW . THAT TM$ WELL WAS CONETRUCTeD IN ACCORDANCE wmi
c. WATER LEVEL Below Top of Casing: Y.5
Fr. 15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT COPY OF THIS
(Use' *' if Above Top of Casing) RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
d. TOP OF CASING IS / FT. Above Land Surface' /� L. 7— ., . 57-02/-1161
*Top of casing terminated actor below and surface may require SI - NATUR • F CERTIFIED WELL CONTRACTOR DATE
s variance In accordance with 15A NCAC 2C .0118. '' /�
e. YIELD (gpm): ! 5 METHOD OF TEST 1 / 1 / S , ^]- , 1 I' e_/
PRINTED NAME OF PE ON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt., Form GW
1617 Mail Service Center — Raleigh, NC 27699 -1617 Phone No. (919) 733 -7015 ext 568. Rev. 7/05