HomeMy WebLinkAboutWELL-03-2016-069674.TIF 01/08/2010 02: 38 FAX 7047361929
Mar,Mar, 2. 2016 1 :38PM CATAWBA COUNTY • No. 3637 P. 1
.0.1.14.. CATAWBA COUNTY Caw s WE1L03.2016-069674
a, w, PublmHealth Department' Subdivision
+.� ��' PINH 368615648676
s�., s Environmental
5 . 4 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOSE
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NAME ON PERMIT: BOJANGLES RESTAURANT INC, 9432 SOUTHERN PINES BLVD, CHARLOTTE
NC 28273
Site Address: 5612 E NC 160 HWY,MAIDEN NC 28660
Property Size: 29aare Feet:284,448.80 Acref:8.83
Directions: Across Hwy 150 from Food Lion at Hwy 180& Hwy 16
Owner/Authorized Representative Acknowledgement of Permit Receipt
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 1 I have received the above referenced pen/IA(3)as
requested in the application for service EHPR•02-1018 23287 ,by the following method(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
4 _ As the property owner or authorized representative I have reviewed and understand the specific conditions
of the permit Issued, and fbrther understand that all applicable regulatory requirements specified under the North
Carolina Laws and Rules for Sewage Treatment and Disposal Systems (ISA 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; 03!0212018 ��� „
7�OwnerlAnthorized Representative Signature / Q
Date 3-L-4.(
•
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by k_bl1r! IA r • IS (name ofperson en ingperm I)
r
Signature .#lrtr,l' t f4.41 LI.. Date/lime
Method; /Fax Email US Mail Other
Owner's request to se b th abo a dicated method of transmittal hi lieu of signature
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vq8• • CATAWBA COUNTY 0 0' .k . Q Case# WELL-03-2016-069674
'k2 %Public Health Department 471§ Subdivision
Q _ Environmental Health Division I PIN# 368615548676
`4 PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 0 0 O }
{_ .t LOT#
/84 s. s JY+' �f
ci -1.F%
NAME ON PERMIT: BOJANGLES RESTAURANT INC, 9432 SOUTHERN PINES BLVD, CHARLOTTE
NC 28273
Site Address: 5612 E NC 150 HWY, MAIDEN NC 28650
Property Size: Square Feet:284,446.80 Acres:6.53
Directions: Across Hwy 150 from Food Lion at Hwy 150 & Hwy 16
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
Drilled
Jason Boyd 03/02/2016
ISSUED BY PERMIT ISSUANCE DATE
chpermit 03/02/2016 08:13 Page I of 2
: ■ 01/08/2010 03:11 FAX 7047361929 10001/001
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4 i-l-e,..KA i c fn : 'Jcti.Sov. 104.4 y••
WELL ABANDONMENT RECORD •
'flri•::nan;can bn aced for sicg:c or:nl;loynle',sells •
\\11 L ABANDONMENT DETAILS
1,Wen Contractor Information: '
AA ` i. (_r��`G S _ 70,Number of+s ells being abadoned:
r\nrel,:+,c duo'1.prn '.y nk•+ !ar.r ■■ I::•'nr-' -,•:'ct 7n.An'o�im ste aolopm of enter remaining in nell(a): Z'�1�' Igo
Z� 1 3 -A pl I:)
�ctt',. cr-'.-srCer:ip;,::and;:-:`.:r
CFOR RATER SLPPI.\'WELLS ONLY:
Ci:r-ry\r:: 7c, 1'%pe of Jlsln feckiTi used'.
((-v3 O c�9 E?4 "�
Ti-f-
2.\\'ell Construction Permit di yJL___ r.rd:c C-✓ p
r..r�•9e:..r::..r1c,:r:,,.rr.:,"U or CbI,ItS 7•�m. t'r. .�; (, , :m:.r. , 711.Ararat*',nldlslnfeelAn[uscd: 1
),Well use(check ndl usd: ' 7e.Sealing mamrlxls used(check all that apPl
Water Supply Weil:
=Agricultural — :m'cipalPoblic s \ca'Ccn its Circ:l deacon
s
Ci•r—c: +all. -
[:(ccl nl(Heating Cooling Sup;151 6/sidential Waa Supply n 'c) Sm:d Cc:acnt G:etc - Ur s)
rinduerial'Co^ncial R:sdrnlial Water Supply(tharcd) _ Cnncrtra Grow: Drill Cr
fir gs
Nat-WW 7,Saec.inIty Grea Grave:
Non- Cate r SupplWell: = Dor tnntc Slur* = Olhcr(av_•ai
l ui de'_1
Injection\ :=Rccos cr` — 7f.For each material selected above,pro'Ide amount of maerlals used'.
inAgili fn\'e l: 24� l b 5
.:lgnifet R::d'arg- -Grnanthre;c: Rem::dJnboq
�Aquife S:oracc and R,cbccn'
=Salinity Darccr
�.Aynifer Test _Sionmsetcr Drainage
JSttbitlenca Control •7g.Prot tie a brief description of the abattdnnm in procedure:
�hsperi:ncntal T<:hnningv 11 II
:Tracer S Ie. t._4. \`r1 Qt •\•�'�C
CGcathemml(Closed Loop) J
]Other *lain under 71)
_Gtr.;herm )(H
aeati *
n 'Cuollnc llcum0 f 1 —
4.Date ssell(s)abandoned: . --2-~
•
go,Well lacallon:
as c:-.� e S N.Cerll9catlom
f:.11::■ Gar r\ra_ , 226 6 1 t--(A 3 z—(b
.5-242-dal Gus` !rr lS0 /f�a Lie 1J-C. S r![.,ofc",ru't l:i t \: 0 .;.
PL)i:ol.\JJr:•-.On.:r•d Dp �� • u'o+ russet nhrnrti0 red PI
1 3L_•\25`f $b Ov •0&WIC •rr.is lornc \CAC•!p•cn(i(i llr s' the ecdll+'/ .
GL�lw O atcnrrluuurircISAA' Crr? J.�0ar2C.0205intllCm:rn;rcrrouStrrorlmd+
Pared IJ::ru Lco'a•n An 1P151
C.r+,__ tool this rr copy of HOC record has hr.ar prouded to the a eft wvmr.
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional Dell details:
p;,+cr.red.r. 6:Icry I.sumlPert You may inc the back of',his page to provide additional s'.dl sac de:ails or cell
R' abandonment details. You may alco attach additional pages if accessary'.
r 5. s. ..rrar tccXR[C1W
..1/. hat coos',m r,a' who!,•;it rnnrinl,le. Fl•.*adoptt cui: i' '�• to .
nn/•Oa'G7' L:0,itr•nm,rno•o,:,,r„e nhav/nntrto∎no con mi:mir m:o ,1,m. ,Par All Wells+ Submit this form st ithin 30 days of completion of ue
abandonment to the follon.img:
6a.Well Ma; Division of Water Resources,Information Processing(nit,
�
,(� 1617 Mall Service Center,Raleigh,NC 17699.1617
fib.'I'ntal Hell depth: ----(fr')
106.For Inleci on\_S'elL In addition to scniiinu the form to the address in 10.1
above, also submit one copy of this form st ithin 30 days of completion of e1i
6e.Borehole diameter:
(Ind abandonment to the fallassing: •
PR Mon of Water Resources.Underground Infection Control Program.
-.__� (ft,) 1636 Mall Service Center.Raleigh,NC 27699.16)6
6d.Water Iet el below ground surface;____,_^—_----
10c.for_MAILLAWaltiaragjaidil In addition to sending the tons to
6e.Outer casing length(If knos,ah —(ft.) the address(es) above. also submit one copy of this form en', uC30te days
s of
completion ofssell abandonment to the count y y health deg om
where abandoned.
. .....,..sir__,-�.,ti. If knma td: .. (ft.)