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HomeMy WebLinkAboutWELL-08-2013-040767.TIF 4,4 _,� CATAWBA COUNTY Case# WELL-08-2013-040767 fin 4 Public Health Department Subdivision MAPLE GLEN V Lei '-C Environmental Health Division PIN# 470003039875 \HI- PO Box 389. 100-A Southwest Blvd.Newton.NC 28658 LOP? 5 /8.2 n NAME ON PERMIT: BRANDON EDMONDSON, 3771 MAIN AVE DR NW, HICKORY NC 28601 Site Address: 1019 HEATHER GLEN DR, CATAWBA NC 28609 Property Size: Square Feet:40,075.20 Acres:0.92 Directions: 10E/ RT MURRAY'S MILL RD/ LEFT SHERRILLS FORD RD/ LEFT LONG ISLAND RD/ RT MAPLE GLEN/ RT HEATHER GLEN / PROPERTY ON RIGHT IN CUL-DE-SAC Owner/Authorized Representative Acknowledgement of Permit Receipt I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced permit(s) as requested in th�.application for service RBPR-07-2013-17714 by the following method(s): Received in Person Facsimile Transmittal (Return form with signature required) /J��� Electronic Image Transmittal/ E-mail (Return receipt required) / /`!G As the property owner or authorized representative I have reviewed and understand the specific conditions of the permit issued, and further understand that all applicable regulatory requirements specified under the North Carolina Laws and Rules for Sewage Treatment and Disposal Systems (15A NCAC 18A .1900), and/or Well Construction Standards (15A NCAC 2C .0100), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply well permitted. Permit Issue Date: 08/08/2013 lei Owner/Authorized Representative Signat• • ____) Date 7—%f.7� Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name ofperson sending permit) Signature Date/Time Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature We want to hear from you. Please take a few moments to complete our customer service survey at: http://www.surveymonkey.com/s/ENCustomerservice ehpermit 07/12/2016 14:59 4" CATAWBA COUNTY D t o7• .• fl Case# WELL-08-2013-040767 L " Public Health Department F � •� . Subdivision MAPLE GLEN ‘K,./. .4 ' � 3 Environmental Health Division r � • I'IN# 470003039875 2� PO Box 389. 100-A Southwest Blvd.Newton.NC 28658 — LOT# 5 4 -' NAME ON PERMIT: BRANDON EDMONDSON, 3771 MAIN AVE DR NW, HICKORY NC 28601 Site Address: 1019 HEATHER GLEN DR, CATAWBA NC 28609 Property Size: Square Feet:40,075.20 Acres:0.92 Directions: 10E/ RT MURRAY'S MILL RD/ LEFT SHERRILLS FORD RD/ LEFT LONG ISLAND RD/ RT MAPLE GLEN/ RT HEATHER GLEN / PROPERTY ON RIGHT IN CUL-DE-SAC WELL PERMIT WATER SUPPLY: Individual Well SETBACKS: 1. BUILDNG FOUNDATIONS 25 FT. 2. EXISTING & PROPOSED SEPTIC SYSTEMS MIN. 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 welt Grouting Depth: Minimum 20 Feet Casing Height: 12" Above Land Surface All newly constructed private drinking water wells arc required to be sampled in accordance with the North Carolina Rules Regarding Private drinking Water Well Testing (15A NCAC I 8A .3800). The fee for this sampling is included in the cost of the well permit. It is the applicant or property owner's responsibility to notify Environmental Health when the well is ready for sampling. Water samples will be drawn from an outside faucet unless otherwise specified. Please note that all water samples are taken during one visit. The processing laboratories have different protocols and timeframes for reporting results; therefore,you may receive several different reports concerning your water sample. For questions or more information, please contact Catawba County Environmental Health at(828)465-8270. Jason Boyd 08/08/2013 AUTHORIZED STATE AGENT APPROVAL DATE chpcnnit 07/12/2016 14:59 I s\3A CATAWBA COUNTY Permit II RBPR 7-1317714 Q�� i Public Health Department Name Michael Vaughn '�:o:.. 'H Environmental Health Division Address 1019 Heather Glenn Catawba NC i K.,,afg q'; Y PO Box 389, I OOA Southwest Blvd, Newton NC 28658 PIN'S 470003039875 842 s„ (828)465-8270 Pas (828)461-8276 TDD(828)465.8200 — Site Plan Authorization to Construct H- 1\ hZZ . O6 , 71' 23' - \°t 5-6r n 50 ___: t 3 0 /0' / 16 0 r H.,.V� n �,t.1i) r- ' Ic'' 7°i its h. N,‘,4 3grz Zo 14'0 .,,C_ Z.8 le. \ti.5: ("&cc fix, 11 ' �q>?cA ULt (�;z l 57, '3 A` _-!-( ,/- GIt I G 0 r Scale Aug 18 16 08:29p Russell Welling Drilling 8286322617 p.2 Print Form WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: t Chris Russell 114.WATER ZONES FROM _TO DESCRIPTION Nagle Well Contractor Nae ••i50 R . 245 R 3245AR. ft. � NC Well ContracrerCdificaliov Number IS.OILIER CASING(for multi-cased wells)OR LINER Of a Iiesble) Russell Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL 0 R. 136 R, 6.25 in- SDR21 PVC Company Name WELL-08-2013-040767 16.INNER CASING OR TUBLNG(geothermal closed-loop) FROM TO DIAMETER m THICKNESS MATERIAL 2.Well plicabi Construction/lcPermit ft: It. ft List c0 opplirab(e well rons»un»n permit;(i.e.UfC.County.State.Variance.etc) ID h rn- 3.Well Use(check well use): - 17,SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural ©MunicipallPublic it. ft in. Geethennat(licating/Cooling Supply) nitsidential Water Supply(single) (L it. In. Industrial/Commercial DRcsideotial Water Supply(shared) 18.GROUT FROM _TO I MATERIAL EMPLACEMENT METHOD h AMOUNT Irrigation Non-N-Wa'atcrSupply Well: ft-0 20 R Grout Poured Monitoring DRecovery IL ft. Injection Wel: IL ft. Aquifer Recharge OGOundwater Remediation 19.Sti`-D)GRA\.gL PACK(if applicable) Aquifer Storage and Recovery OS:dinity Battier FROM I 'TO MATERIAL I EMPLACEMENT METHOD c R. Aquifer Test DStonnwater Drainage t Experimental Technology DSubsidence Control rt. 1 ft. I Geothermal(Closed Loop) , OTracer 20.DRILLING LOC(attach additional sheets If necessary) FROM TO DESCRIPn'ONfrolic r,barrios.roipmr'kt)pc,goad On.etc.) Geothrnnal(lieating'Cooling Return) DOdtcr(explain under 621 Remarks) -0 ft 131 n' Dirt 4.Date Well(s)Completed: 08/18/16 Well FRN 131 ". 245 245 It- Rock ft. ft. St.Well Location: Brandon Edmondson Oakwood fI. ft. Facility IDN if applicable) ft. - �n Facility/Owner Name ( p' 1019 Heather Glen Dr, Catawba NC 28609 R w ft. ft. Physical Address.City.and Zip Catawba 21.REMARKS County Parcel Identification No(PIN) 5b.Latitude and longitude fa degrees/minetes/seconds or decimal degrees: (ifwel field,one laVloog is sufficient) 22.Cert>fie n: 35' 40.047' N 081' 01.001' W r La y� ar� 08/18/2016 of Ce 'ell Conctor Dare 6.1s(are)the weil(s)ij'^F�{ giamre Pertnanent or O3'empurary 5v aignb,g this jOrm. I hereby sort That the.e11(s)en(nun)contracted in accordance 7.1s Ibis a repair to an existing well: Oyes or RDNo with 154 PICA C 02C.0/00 or 154 NCAC 02C.0200 Well Construction Standar&and Ihar a If slily is n pr>'.fill out kmnwr:well cons e.mion information trod captain the marline i‘ihe cal''of rhes recant hat been pmvded Ic the well owner. repair nude,-01.emorke scchanwmthe back of this form. 23.Site diagram or additional well delailm You may use the back of this page to provide additional well site details or well 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only I GW-1 is needed. Indicate TOTAL NUMBER of welts construction details. You may also attach additional pages if necessary. drilled: SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 245 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For maltifle nettle list all depth,irdifferent(example-3,0)00'and 2@1001 coesirection to the following: 10.Static water level below top of casing:50 (ft.) Division of Water Resources,Information Processing Unit, If water level is above casing,use''+^ 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 6.25 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a Air Drilled above,also submit one copy of this form within 30 days of completion of well 12.Well construction method: construction to the following: (La.auger,maty,cable,direct pleb,etc.) Division of Water Resources,Underground Ihjection Control Program, FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) 40 Method of test: Air 24c- For Water Supply&Injection Wells: In addition to sending the form lo the addrsas(cs) above. also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount: 2/3 Cuo completion of well construction to the county health department of the county where constructed. FortnGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Roiced 2-22-2016