HomeMy WebLinkAboutWELL-02-2016-069463.TIF 4� * CATAWBA COUNTY Case# WELL-02-2016-069463
Public Health Department Subdivision FRED MCCALL UNREC
Q Q'1 ,'�,
Environmental Health Division I'INtt 460604902708
41' PO Box 389. 100-A Southwest Blvd.Newton,NC 28658
LOT# 29-30
X842 s.
NAME ON PERMIT: LEAH DEVLIN, 2319 CHURCHILL RD, RALEIGH NC 27608
Site Address: 7940 KEISTLERS STORE RD, SHERRILLS FORD NC 28673
Property Size: Square Feet:67,518.00 Acres:1.55
Directions: Slanting Bridge Rd, Keistler Store Rd, on left at end of road
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 the application for service EHPR-02-2016-23207 , by the following method(s):
_ Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/ E-mail (Return receipt required)
--b 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: 02/23/2016
1Owner/Authorized Representative Signature
Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted�b/, p, r `It I7_ •• �a A as (name of person sending permit)
Signature C �/ W v , J Date/Time z/ i 0 I IC'
Method: Fax VEmail US Mail Other
Owner's request to sen by the above indicated method of transmittal in lieu of signature
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ehpermit 02/23/2016 13:21 Page 2 of 2
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�gA • CATAWBA COUNTY 0 • io:��f case# WELL-02-2016-069463
7*rt l Public Health Department f • - :1]F Subdivision FRED MCCALL UNREC
L 460604902708
$ Environmental Health Division
-1,0
> PO Box 389, 100-A Southwest Blvd,Newton, NC 28658 PIN//
L �0 i LO"flt 29-30
1842 a •_ ti
NAME ON PERMIT: LEAH DEVLIN, 2319 CHURCHILL RD, RALEIGH NC 27608
Site Address: 7940 KEISTLERS STORE RD, SHERRILLS FORD NC 28673
Property Size: Square Feet:67,518.00 Acres:1.55
Directions: Slanting Bridge Rd, Keistler Store Rd, on left at end of road
WELL ABANDONMENT PERMIT
Wells shall be abandoned in accordance with state regulations:
Article 15A North Carolina Administrative Code Subsection 2C
The Well Abandonment Report must be submitted to the Catawba County Environmental Health within 30 days upor
completion of a well abandonment.
Well contractor must schedule well abandonment inspection with Catawba County Environmental Health.
WELL TYPE
Bored
Robbie Phelps 02/23/2016
ISSUED BY PERMIT ISSUANCE DATE
ehpermit 02/23/2016 13:21 Page I of2
May 25 16 11:53a Advanced Well Drilling, L 8282412445 p.2
y r
1- WELL ABANDONMENT RECORD
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.f�.\.7-1,11 v _k North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1.WELL CONTRACTOR: , 5. WELL RETAILS: /,,,y
r a.Taint Depth: / R. Diameter.
Well Conlme(+ (Individual)Name b.Water Level(Below Measuring Pointy: Z.'S ft.
AA/,-9A/6-e � t f // KJ r. (/ ti 4 L C Measuring point is 2 R.above land surface.
Well Contractor Company Name ✓ /�
STREET ADDRESS Z Z n/Z 1 /N ." .i IO 6. CASING: Length Diameter
Diameter
C dill J _ /I ,C r J J"L 6 a.Casing Depth(if known): V ft. 2-a in.
p City or Town State Zip Code b.Casing Removed: ..$' R. 2. ° m-
(yLfi- )_Lt/l /3 DO
Arca code-Phone number 7. DISINFECTION: "•Z' 1 hi )/f .l)1 •
•
2,WELL INFORMATION: (Amount of 65%0-75%calcium hypoddorite used)
SITE WELL ID#(if applicable) S. SEALING MATERIAL:
heal Cement Sand Cement
STATE WELL PERMIT k(if applicable) •
// // 7 Cement lb. Cement lb.
COUNTY WELL PERMIT a(if applicableWC(1--OR—ad)In'Q(a9'I hot 7 Water gal. Water' gal.
DWQ or OTHER PERMIT if(if applicable) Rentonite
WELL USE(Circle applicable use): Monitoring Residential
Bentonite Ib,
Municipal/Public Industrial/Commercial Agricultural
Type:Slurry_Pellets_
—
Recovery Injection Irrigation Water gal.
Other(list use)
• Other
3.WELL LOCATION: Jr-Off p gel /sat/a/d COn�tr.-s<<
1 • Type material o/r-O f /t'C/ J�
COUNTY �/}Iv,lt.)�'>- QUADRANGLE dNA1ME'_) -p
NEAREST TOWN: _S/,^� I l i L.•t d N` C • .2 )4 3 Amount
(Saco/Road Name,Number,Community,Subdivision,1.01 No.,Pared.Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TOPOGRAPHIC/LAND SETTING: S/oe..) l r--
Slope Valley (11&10. Ridge Other-
(Circle appropriate setting) •
�j G 5 2 May be in degrees,
LATITUDE r/J minutes,seconds,or in a
^t., I7� a ? decimal format 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LONGITUDE f[13 0 / Ir
Latitude/longitude source: ON Topographic map form showing total depth,depth and diameter of screens(if any)remaining
(Location of well must be shown on a USGS tope map and in the well,gravel interval,intervals of casing perforatiors,and depths and
attached m this form if not using GPS.) types of fill materials used. 7
4a.FACILITY-Theca=of the business where the well is located.Complete 4a and4b. S' / '7 C.i— Z �! 1
(If a residential welt,skip 4a;complete 95,well owner information only.) 11. DATE WELL ABANDONED
FACILITY ID k(if applicable) I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY WITH 15ANCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF
THIS RECOB n Has BEEN PROVIDED T 776 WELL OWNER.
STREET ADDRESS
� VC' 4, 3D DATE or Town State Zip Code • IGN RE OF CERTIFIED WELL CACTOR DATE
4b.CONTACT PERSON/WELL OWNER:
NAME .e.. 11 (f2 01,-/ti SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
Vim- ‘hy o n (The private well owner must be an individual who ptnonnlly abandons his/her residential well
STREET ADORESS_Zj J 9 Git✓e l al a LI in accordance with 15A NCAC 2C.0113.)
Init;5k /LC • .2- '7 4 41
City or Town State. Zip Code HUNTED NAME OF PERSON ABANDONING TIE WELL.
( 3/ Y )- 47 9E '? V7 5
Area code-Phone number
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management, 1617 Mail Service Center—Raleigh.NC 27699.1617, Phone No.(919)733-7015 etc 569. Rev.5/06