HomeMy WebLinkAboutWELL-04-2016-071350.TIF z.p,A CATAwbA COUNTY Case# v
.¢ 11 4. Public Health Department Subdivision OLD MILL SUBDIV
iiiway Environmental Health Division PIN# 461901294697
PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOT# 13
NAME ON PERMIT: SARAH LYTTON TATE, 1790 SW POWDER SPRINGS RD, MARIETTA GA
300644154
Site Address: 1317 KNEBWORTH LN, CATAWBA NC 28609
Property Size: Square Feet:22,651.20 Acres:0.52
Directions: Mollys Backbone from Mumbo Rd, Left on Rowe St, Right on Knebworth Lane & lot is on the Right.
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.
lam% , As the property owner or authorized representative. I have received the above referenced permit(s) as
"
requested in tthe application for service EHPR-10-2015-22595 by the following method(s):
1?/ Received in Person
Facsimile 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 (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: 04/18/2016
--wner/Authorized Representative Signature /^ 47r- i LlIc`---
(((Date f)r) 7-236
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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ehpcmtit 04/19/2016 08:58 Page 3 of3
A CATAWBA COUNTY 0 it. 0 Case# WELL-04-2016-071350
,C �7 Public Health Department 77r}ti li } 31' Subdivision OLD MILL SUBDIV
II�. ,1 Environmental Health Division r 5k • '+ • PIN# 461901294697
PO Box 389. 100-A Southwest Blvd,Newton.NC 28658 LOU 13
/8.2 zM = 7
0 80
NAME ON PERMIT: SARAH LYTTON TATE, 1790 SW POWDER SPRINGS RD, MARIETTA GA
300644154
Site Address: 1317 KNEBWORTH LN, CATAWBA NC 28609
Property Size: Square Feet:22,651.20 Acres:0.52
Directions: Mollys Backbone from Mumbo Rd, Left on Rowe St, Right on Knebworth Lane & lot is on the Right.
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
Robbie Phelps 04/18/2016
ISSUED BY PERMIT ISSUANCE DATE
ehpermii 04/19/2016 09:14 Page 1 oft
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®s JUL 13,2016 03:31A WHISNANT WELL SERVICE
000-000-00000 page 1
Imo
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DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES ,�•~.
DIVISION OF WATER QUALITY !
GROUNDWATER SECTION
1636 MAIL SERVICE CENTER
•
WELL ABANDONMENT RECORD - RAI' OH, N.C. :699-163t ;7-.
CONIRACI'O•: a I
1,WELL LOCATION: (Show
i . ,
a Sketch of t lOcation on back of form.) ' ^~---
.Nearest JTown:
� I H� County: i 10 ' P , yl •
/,- 1 J bile , LA. I. LAl
(Rona Comum ity,Subdivisi,t/I, .et. No.) �C adnngle No, �'�`�-
2. OWNElt:C.504 4k 'lib/ C
J. ADDRESS- /2/7 /J 1' piQ( (x,El,.l�( J�,,� -_ - •CCC.��� WELL DIAGRAM:Drove a detailed stretch of the well
4. TOPOGRAPHY; draw,slop ailltop,valley, flat showing total depth,depth and'diameter of screens remaining an the
wall,gravel Interval,Intervals of easing per-tared S.and depths and
S USE OF W ELL: _ DATE_ typos
of fill mattolnls used.
6. TOTAL DEPTH: /51:17 DIAMETER: O t
119 7. CASING REMOVED: 1� �: I k
diameter /� V irt. C
t
•
_—..—___ lie. //
R. SEALING MATERIAL..: �(nirl ///f n , ,,r
�'enl smut Sp t1s3,y, en IId11""`
bogs of cement bags of cement
•
gals.of writer 6- yds.of sand l/_
gals.a(water V /i-
--
Type material
Amount
9. EXPLAIN METHOD EMPLACEMENT OF MATERIAL
I do h e certif thntthli cell Abort is true and exam/
nature of Can n or Agent Date
WEL ,LOCATION: Draw a location sketch on the reverse of this sheet,showing the direction and distance of the well CO at
least two(2)nearby reference pointy sorb Ili roads,Intersections and.01-Corns. Identify roads with
State Highway road klentfftcatlon numbers.
Submit original to the Division of Environmental Management,one copy to the driller,and one copy to the owner,
GW-30 Revised 9113/99