A30 37CAppllcation Dute: — ^ • ' �% �,.1�� � f ���� �� Taz Map: f�` .�
Amonnt Paid: 7 00 �� ►•�,l r� ���,�,� Parcet#: �_,�_._
Receipt #: I $3 3 r. ;1 7 n p �
:��'II3'Y�`�`�33Il3,L^3.�tt+^J.L._7H�d7t3A�:i[] .i
�� � G 3S Application for Services
� Services B.te uestecl �
� Improvement Permit (Site JEv���at�o�p) �� s4 �..,Ll�Constni�►n 1�uthorization
$2Q0.00/$300,00 i�> �00 � d •'- `� `��'� ee is d endent on the e of s stem ermitted
0 Ii�obile Home Replacemen�-,br �uilding Addition ,, O Fermit Revision �
� Z5.00
. � I 50_0�.(if site visit reauired) . • ' . _ _ _—�
Permit
, ❑ Repair of Exi3ting Septic Syetem
.�. • A�niication: No Char�e/ CA �I50.00 or
1) �pplicant Ynfqrmati n: . . . .
Name:
�Address: • A • , • •
�) Atame and address of current owner (if different than a plicant):
Name:
Address:
aee�i�e..��-2`7��i �
3) Property Description: Lot Size: Subdivisiob:
Address and/or di�ections #o Property: �
Phone (home): �� 2 - g 3SS .
(work/ce11): /'� �L � � 5'g3 � G, 3 6
. �r .
Phone: �
�
#:
- � yes no I�oes the site contain any jurisdiciionaI wetlands?
❑ yes ❑ no Does the site contain any existing w�st�water systems2.
❑ yes � no Is any wastewater going to be generated an.the site other than domestic sewage? �
0 yes � no Is the site subject to approval by any other public agency? t�'O�'''�
� yes � no Are there any easements or right of ways on this property? �a„',i►� �
(if `yes' is checked, please provide supporting documentador►) � Gd�
4) Proposed TJse and �ype of Structure: ^ � u�i�� N
�Residential . • • • �,� ) �'C.� � y
CI New Single Family Residence Maximum number of bedrooms: 1 Occupants: �.. �'`
i� Expansion of Existing System If expansion: Cu=rent�number of bedrooms:
❑ Repair to Malfunctioning System Will there be a basement? � yes � no With plumbing fixtures? ❑ yes O no
❑Non-Residenti�l .
Type oibusiness: Total Square footage of Building:
Maximum number of employees: Ma ,imum number of seats: _
� V4��ter �upply: ❑ New well ❑ Existing Well ❑ Community Vflell 0 Public Water ❑ Spri.ngw..
Are there any existing wells, spriFigs, or existing waterlines on this pmperty? CI yes ❑ no
Please note any Irnawn ground water restrictions or sources of contamination:
G) ff applying for `�uthorization to Construct', please itidicate pre%pred system type(s):
❑ Conventional ❑ Accepted � Innovative 0 Alternative ❑ Othet - ❑ Any
�
I cert� that the infonnation provided a ve is cornplete and correc� I also understand that if the infonnation prouided is
inaccurate. the site is subsequently ¢lt�d, or the intended use chgnges, all permtts and approvals shall be invalid.
� _ � - - 7-2s-2or7
Date
�' Supporting documentation required.
a Permiis are v�lid for either 60 months or are non-egpiring when accomp�nied by an approved p1aL
Q ..� completed `Lot Preparativn' form must accompany any applicatfan requiring a site evaluation.
���.sf ���.���
�--�- � � ����
IE ua�n�r � aa�am�cn. �.m.Il IE3Co � Il�lEn.
WELL PERMIT
(New_ Repair�
Tax Map: � Parcel: 3�
Subdivision:
Applicant's Name: r p� j f�( � w� �,�
Mailing Address: ��rJ �„ �
�,� �ttG Z� 5'1 �{
Phone Num6ers:
Location of Property:
Lot:
Permit Cor�ditions:
1.) See attached site plan for proposed well location.
2.) All applicable State and County regulations governing construction and setbacks apply.
3.) Permits expire S years from the date of issue.
4.) Issuance of a permit does not guar�ant�e a potable water supply
Other Conditions/Comments: Po��=fF�-1 � i �� �iK��''
Permit issued
�Tew Well:
EHS/Date
Location:
Grouting:
Well Log:
Wetl Tag:
Pump Tag:
Air Vent:
Hose Bib:
Casing Height:
Concrete Slab:
Well Driller:
Pump Installer:
Approved by:
Additional Comrnents:
Date Sample Collected:
EHS:
Person County Environmental Health
325 5. Morgan St.,Suite C
o..,.ti�.,, nir ��c�a
�
Date: 7—Z��-�7
Certifcate of Completion ,�,/
ULiner:
C� � � _ ��' ' t��' EHS/Date
� t O�f,�' � ' Sy� Depth: �i `
Grout: ��"`i �/��
l pp' �v,,,,�;� DAbandonment:
Date:
Method/Materials:
License #:
License #:
Date:
Date Results Mailed:
Phone:336-597-1790 fax:336-597-7808
„ncr„
WELL CONS�RUCTION RECORD
This form cao bo used for cinglc or multiplo weUs
i. �Yep Contrac%InformaBon:
/G �yil�G�
Wep Coauacoor Naase � �
y3 %� C'
NC WeG Contrncto� G:rd6cation Numbcr
�/ G!� �L�/71'PI�S � C.
Company Neme
Z. Wetl Cbnatrucdaa Pesmit #:
lJst a!1 appl�cabfe Nrff peruila (t.z Coustj: Sta1q YariancG lnfecrlon, erc)
3. Welt Use (cheek well ase):
DAgricultaral OMuaicipaUPubGc
OGeothennal (Heating/CooGng SuppTy) �idential Water Supply (singtc)
�IndustriaYCommerciai OResidenti8l Water SuPpIY (shar�)
QAquifer Rec6atge OGroundwater Rwx�lia6on
4Aquif�r Storage aad Recovery I]Satinity Barrier
OAquifer'hs� O5tormwaterDrainage
❑Experimantal Technology 17Subsideace Control
[]Geothermal (Ciosed LooP) OTracer
OGeothermaf (FieatlnFJCaoling Retum) ❑Ot6er (ezolain under.1121 F
4. Date WeU(s) Completed: �o!�`%� WeU ID#
Sa. Well Locatlon: '
_._T��/ � -r
FoeilirylOwrierNoma Fe iUtyiD#{ifapplieabk)
_��✓0I� l.1�N . ��Bp2�_/Y�
Physical Addres,� �y, �,a z�
r�S�l�
C�ti' Parccl Id�:ntiGcation Na {PW) .
Sb. Latltude and Longitude 1n degreeslmtnutes/secands or declmal degrees:
(ifwei[ fkld, one laUtong is sufficient)
x 3�°/��3��N���`f`l�.•50�`���� w
6. Is (are) t6e well(s):�eTmanent or OTemporary
9. Is thfs a repalr to an e�sdng weli: ex or ❑No �
{(thLr fs q repp(r, fiU out lmo�tri we1! cotutruct on Injorntation and esp(airi dte nature of 1he
re/wlr iuider ttZi rnmarks seclloq or on the back af ehlr jorne.
8. Num6er of wells constructed: �
For xtuldple fnfectiori or non-iwtersupply urUs DAZYwdth thesame rnnshucNon, j`O!! Cpp
submit oneform.
Q�
9. Total well ctepth below Iand surface: �O� �g,�
For multirfe �ticlls Ust a!! deptlu �'J'd�erent (esample- 3(`ya 200' anJ 2QIOtY)
O� ,
I0. StaUc water level below top of castng: �p�,j
{f x+�eter leve! [s abova casing, use "+" /
!i. Borehole diameter: [! / (In,)
12. Well constructloa methods � /� Gl ��'�
(i.e, auger. rotery, cabk, dicect push, ecc.)
Far Imeroel Use ONLY: :
22. Certificatlo •
, � � �,
,r „
Signatsm o tkd e Coa r Date
8�� signing jorm, iereLy cmffj� that the x�ell(s) xns (wrr� construcled in acrordance
xith !JA NCAC QZC .0100 or ISA NCAC 02C AI00 iYell Construcdon Standords and thnt o
copy ofth(s rernrdhas beea provi�tedlo tke xrll o�tner.
23. Site diugram or addiHonal wetl detalls:
You may use tho back of this page tn pcnvide additional weli aite details or wdl
consuuction detaits. You may also attach additional pages if necessary.
SUBMTTTAL 1NSTUGTIONS
2Aa �or All Welis: Submit this fomt within 30 days of completion of well
consuuction to th$ following: '
Divisioa of Water Resources� luformallon Pracesstng Uati,
1617 Mail Secvice Center, Ralelgh, NC 27699-1617
ZAb. For iniectiej,�, Wells ONLY: tn addition to sending the form to the address in
24a above, also submit a capy of tl�lis form tivithin 30 days of eompletion of tivell
rnnstructio» to the followiug:
Dlvlsioa of VVater Resources, Uoderground InJectton Control Program,
FOR WATER SUPPLY WELLS OIYI.Y: 1636 Mail Service Center, Raieigh, NC 27699-1636
13a. Y[eld m 24c. For Water Supply & ln(ection �Velk:
tgP )�_.__ Method of test: P �o submit one copy of this forcn �vithin 30 days of c4mplation of
13b. Aisinfeedon type: Amouat: �y C�f - well consuucdon to the county health depamnent of the connry where
consttucted.
Focw OW-1 Nonh Carolina Departmeat of Environment and Natu[sl Resowras — Divtsion of Water Resources Revistd August 2013