WI0100017_Inspection_20130807

=, North Carolina Department of Environment and Natural Resources
Division of Water Quality—Aquifer Protection Section
INJECTION FACILITY INSPECTION REPORT
PERMIT NO. WI 0\ Ooo
DATE OF INSPECTION: -7 l
_j
INSPECTOR: Andfe e Moo t
NAME OF PERMITTEE(S) 0-4
MAILINGADDRESSOFPERMITTEE '73o-7 29'173
PHYSICAL ADDRESS OF SITE(if different than above) Iti a lm ht E4W t� 0,,\jc L4 h. 1,VEC Iyc z&7v b
iL
PERSON MET WITH ON-SITE Graf kt� N w�I ; TELE NO. $2I— SS l- G +7
WELL(S) STATUS:
_Existing and operating Class V Well
Existing well proposed to be converted to Class V well
Proposed/not constructed
LAVLONG OF WELL(S) 3S-. 2`l. 411 -Sa,09.32-
Appx. distance of well to property boundaries: Go
Appx. distance of well from foundation of house/structure: 2 z �cc�
Appx. distance of well from septic tank/field (if present): Iwo Ft<k
Appx. distance of well to other well(s) (if present):
Appx. distance to other sources of pollution:
Flooding Potential of Site: _high _moderate low
Comments:
Injection Facility Insp.Report(Rev. Sept 2009) Page I of 3 Pages

4
DRAW SKETCH OF SITE ABOVE (Show property boundaries, buildings, other wells, septic tanks/drain fields, other
potential pollution sources, roads, approximate scale, and NORTH arrow)
�tG /t'1"Tucllt v/
E
i
Draw Schematic of well above showing TD, casing depth, grout, etc.
i
I
Injection Facility Insp.Report(Rev. Sept 2009) Page 2 of 3 Pages

Well Construction Information
Date Constructed: 7 / 11- 03
Well Contracting Company: 64[ums ��4 O✓
Well Driller Name:
J NC Well Cert. No.: 213?'
Address: Qa bay yz�, Fllrvboror/vc Z'r yo
Telephone No.: S®o - 9-7z- F7 3r. ; Cell No.:
P
Email Address:
Proposed Depth of Well(s):
Total Depth: b m s Total Depth of Source Well, if present:
Casing:
k! Depth: rzo ' ; Diameter: " ; Type (gay. steel, PVC, etc.): r(i Stick Up: — os ft
Grout:
Depth: 20 ; Type (cement, bentonite, etc.): ; Placement (pumping, press. etc.):
Well ID Plate Present (Y or N): N ; Heat Pump ID plate present (Y or N):
Influent spigot(Y or N): Effluent spigot (Y or N): Y _
Well Sampled? (Y or N): Y ; If Yes, Lab Sample ID numbers: 1 PDS 1 kv T O1 OOO c7- 2'w F
JP081ws01 odor - CFF
Static Water Level:
4, Injection Information (if applicable):
Injection Rate: GPM
Injection Pressure: PSI
Injection Volume: GPD
Temperature- Summer: F°
Temperature- Winter: F°
Comments/Notes tvc11 co�sk ���� r .[i ��] ab+ ti��l - -a p,e�u 7 T.ef<[4,,v7
S,).,c4 �) Np wet/ _�y�J'—ryy o�✓s••7 `•� ,`.,..ter is _
Injection Facility Insp.Report(Rev. Sept 2009) Page 3 of 3 Pages

_1 __ --
_b
_I
T
_�
�'�
l
i
9
5

utherford County,NC Print Map Page 1 of 1
laaaaza
r.
983 t1A7
i� �rFc
IIII 0"JCS
_7
163231$
19�U2.e
iu
H18462T§
103,
18992+39
Rutherford County, NC
Disclaimer:The information contained on this page is NOT to be construed or used as a"legal description".Map information is believed to be
accurate but accuracy is not guaranteed,
htcliv ww webgis net Anderson&Associates,Inc. htlo:Uwww.endassoe.com
j
C
a
1
http://arcgis.webgis.net/ne/Rutherford/printable.asp 8/8/2013

r
I
s
"s
G
i