HomeMy WebLinkAboutWELL-04-2016-070960.TIF a ■
...ROM :COOL PARK PUMP ING, INC.
Y FAX NO. :828 256 2926 Apr. 12 2016 09:46AM P1
CATA\\'BA COUNTY C7:51.:C7:51.:@
• Subdivision BRADIE WHITE AND OTHE
• I Public Health Department
G ; _•(;,: . Environmcnlal Health Division PINS 372416934269
PO Box 389. 100-A Southwest Blvd,Next ton,NC 2$658 LOTS 5
�t ly
NAME ON PERMIT: ERIC WHITE, 3121 44TH AVE DR NE, HICKORY NC 28601
Site Address: 3203 SULPHUR SPRINGS RD NE, HICKORY NC 28601
Property Size: Square Peet:17,424.00 Aeres:0.4
Directions: Springs Rd to Sulpher Springs Rd, House is on the Left
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.
[ referenced As the property owner or authorized representative, I have received the above ree permits)as
Y requested in the application for service EHPR-03-2016-23338 by the following method(s):
Received in Person
_ csimile Transmittal (Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
■
`' 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 (ISA 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: 04/08/2016 r
Owner/Authorized Representative Signature _. ' °- '
Date ii` PC' Y 49
Documentation of Permit(s)Transmittal •
(permit transmitted by electronic or other means)
Permit transmitted by _2 �J t 0 � e Ili (name of person •e?din permit
Signature .i:i_u. •.. A 1* Date me ��?yur v� B.-is
Method; _Fax, ,./ Email L'S Mail Other •
Owner's request to send by the above indicated method of transmittal in lieu of signature
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chp:ntit 04/08/2016 08:36 . Page 4 0f4
4-6A CATAWBA COUNTY a Lit o- r' f D Case# WELL-04-2016-070960
r Public Health Department T�• Subdivision BRADIE WHITE AND OTHE
f't, e i4 ?'ti. _ '•' • PIN#
t Environmental Health Division f . _ 372416934269
� °� PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 I. � LOT# 5
1842 4—.-P _ • •
NAME ON PERMIT: ERIC WHITE, 3121 44TH AVE DR NE, HICKORY NC 28601
Site Address: 3203 SULPHUR SPRINGS RD NE, HICKORY NC 28601
Property Size: Square Feet: 17,424.00 Acres:0.4
Directions: Springs Rd to Sulpher Springs Rd, House is on the Left
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
Megen McBride 04/08/2016
ISSUED BY PERMIT ISSUANCE DATE
ehpermit 04/082016 08:37 Page I oft
A -2 WELL ABANDONMENT RECORD
.,,�F j,)Y: � North Caolma Department of Environment and Natal Resources.Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETADS: �1
,Taal❑qda C1"1 R Diameter: Li m
Well Contactor(Individual)Name ' b.War level(Below Measuring Pete): 30 R
Measwi„gromt e 0 R above lad Airtime.
Wef Qsmactor Company Neale
STREET ADDRESS 6. CASING: Length Diameter
a.Casing Depth(Etmwek 94 R in.
City or Town State Zip Code b.Casing Removed: ii R in.
Area ode-Phone aumbm 7. DISINFECTION: Ghl0fWIG -k61G45
2.WELL LVFORMATlON: (Amass of65%-75%ukima hypoddoete used) •
SITE WELL ID 0(if applicable) L SEALING MATERIAL:
STATE WFI.t.PERMIT S(Rapiiobie) Neat Cta d &S Came
COUNTY WELL PERMIT I(ifapplicaNe)*ELI:01.1o16.070960 I0. C We lb.
. Wear tt gal. W IN
gel.
•DWQ or OTHER PERMIT I(if applicable) Atalanta
WELL USE(Cade applicable use) Mealurhg tfal gm, lb.
MonieipWPaNic IedasbfalC.aswdal Agrtee
Raevery iajitte Irrlgagoa Typo:Slurry_Pellets_ •
Other(list we) Water �.
IIIhm
3.WELL LOCATION:
COUNTY C.Ct4AWba QUADRANGI.ENAME Tyre material Cleft 7 cloy
NEARES'rwwN: 370 Sv .,, ( •fi . ,is . Amount 11 pas
(SamlRo.d Nast Numbw,Camo„ei y,Sedate..Lot No..Pa.Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAIL
TOPOGRAPHIC/LAND SETTING: ditch, fit( did Packed info welt rApped wilt-
.
Slope Valley (ED Ridge Other CDnCrC4C
(Cirek appmprine )
urrnmE _ 3, 771317 May be od`pees,
masa.maids,ash d
LONGITUDE 31. ab0677 deal forma 10. WELL DIAGRAM:Draw a detaledsketch of the well no the Net of this
Latitude/longitude source: GPS Topographic map fam showing cal depth,depth and diameter of meats(if any)remaining
(lacmtbe cf well new be shwa +a USGSapo map and inthe well,gavel Steroid,imavds of casing perforMiom,and depths and
snacked b*slam rnat wing CPS) types of fill menials oat
4 F A C I L I T Y-T h e sates of ea lamina wara do.vD oboned Canals ea malt
Otte emtSwetdrip*complete Nwaownwmfeem.daaonly.) 11. DATE WELL ABANDONED yINIlb .
FACILITY ID 5(ifapplicable) '
NAME OF FACILITY I DO HEREBY CERTIFY THAT mrs WET.WAS ABANDONED IN ACCORDANCE
WITH I IA MAC iC.WELL CONSTRUCTION STANDARDS,AND THAT A COPY CF BEEN PROVIDED STREETADDRESS THIS RECORD HAS PROVIDED TO THE WELL myna
City or Town Sum Zip Code RQflTIJZZ OF w CToQ DATE —
A6 CONTACT PERSON/WELL 111 OWNER;
NAME Etc.Wf11l&i • S1QtA ParvA� %�
3I I tit NI Dr NE oa.p ae a.awamvara and 8d AB""DO11p GTIa WILL ore
STREET ADDRESS 3 7 in aceadao ma ISA NCAC 2C DID.) l�9HY.t(d+aadm makte teaidndd+dl
Jai dry NFL 3tcol Ent while,
City orT Zip Code MOWED NAME OF PERSON ABANDONING IRE WELL
(928 )- 38J-Bozo
Area code.now nm,ber
Submit a copy to the owner and the original to tie Divides of Water Qualty walls 30 days.
Attn:faformatlee Mea geaeat 1617 Mail Semite Cole,—Raldgi•NC 27699.1617, Phone No.(919)733-7015 eat SLg. Fenn.5/06
Rev.5/06.