HomeMy WebLinkAboutWELL-06-2016-073519.TIF 1a• • CATAWBA COUNTY
Case#
Q,t Public Health Department Subdivision CLEAR SPRINGS
6 iii®}W H Environmental Health Division I'IN# 374519514340
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a PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LOTH 1
78.2 �,
NAME ON PERMIT: RODRIGO GARZA, 5366 SPRINGS RD, CONOVER NC 28613
Site Address: 5366 SPRINGS RD, CONOVER NC 28613
Property Size: Square Feet:24,393.60 Acres:0.56
Directions: 1-40 W to exit 126, McDonald Pwy & take right to Springs RD and Turn Right drive 2-3 miles-property on the
right after Lee Cline RD
Owner/Authorized Representative Acknowledgement of Permit Receipt
s� I certify that I am the owner or authorized agent(owner's authorization required) representing the owner of the
.roperty described above.
As the property owner or authorized representative, I have received the above referenced permit(s) as
■ requested in the application for service RBPR-05-2016-23902 by the following method(s):
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 - 1 permitted.
Permit Issue Date: 06/15/2016
3Owner/Au orized epresentative Signature ..— i/
Date #
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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yygA \ CATAWBA COUNTY IDS 07} Case# WELL-06-2016-073519
Q -\ Public Health Department S Subdivision CLEAR SPRINGS
�� f 374519514340
Q y „�; Environmental Health Division � PIN#
\911yi PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 _ 3 7. LOT/ 1
/842 M S. - A
NAME ON PERMIT: RODRIGO GARZA, 5366 SPRINGS RD, CONOVER NC 28613
Site Address: 5366 SPRINGS RD, CONOVER NC 28613
Property Size: Square Feet:24,393.60 Acres:0.56
Directions: 1-40 W to exit 126, McDonald Pwy & take right to Springs RD and Turn Right drive 2-3 miles -property on the
right after Lee Cline RD
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 06/15/2016
ISSUED BY PERMIT ISSUANCE DATE
ehpemiit 06/15/2016 10:18 Page 1 of2
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WELL ABANDONMENT RECORD
1l cir North Caro lina Depart=ofEgv rat>menz and NannI Raou ca Division of Want Quality '
- WELL CONTRACTOR CERTIFICATION it
1.WELL CONTRACTOR: a: WELL DM US:''(I .
• a.Tool Depdu 10 R Maraca: in
WC1Ica (Idivibd)Nemo ' . b.Water Level(Below Maiming Poim): lA 1L
Masada p a la 0 IL above lard aatbcc
wdl rmmttor Company Nam .
STREET ADDRESS 6. CASING: Length' Dudes
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..Cluing Dept(tkrct 30 D. 0 in.
cry or Town Stag Zip Code b.Cuing Rennet 11(,,,�R 0 m
Arta code-Pita.mamba 7. DISINFECITON: I— l_p I) 605 •
2.WELL INFORMA770It
(Amount at65%-75%cad=bypochloritcJmad)
MSS WELL mA(If.pplhbM) S. SEATING MATERIAL •
SATE WELL MEMO'A Qhppiin:le3_ Nat Curt Sad dOeatat
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Caned 1p count,WEllP�OTA(d appaab )WEU06•5016-07351q warn lb.
Pi.
DWI)or OTHER PERMIT6(iapphabk) Bakal .
WELL USE(Cinder imitable ter Mealbdag ( ... .-.) Raaoat lb.
MankipVAbRe Iademid/Ctatndal ArcanuN - - Mr Bliary_Pd1eO_
Rao...7 Ljedlm lydptaa 11 War p1 •
OmerOia ea) th INuse. .OXMPef WP.jt
on '4hv Nowt/ • Stdac
3.WELL LOCATION:/� �` The marred Cleaf)11l l dirk
00(1NiY LCD$14O QUADRANGLE NAME
NFARrsTwWN: 5366 FiciAll a, Can mitt Amount "K 6acLHet Sroopc •
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(6ew/Pt.ANa.,Nmba Cam,Sdrt.bim,la New,Pa:TbO.e) 9. EXPLAIN METROS/4 F EMPIACEPAINT OF MAT�RTAL•
TOPOGRAPHIC/LAND SErmw: 4lrk roahte . ln(W, wtJL MhoI "�
Slope valley OD Ridge Oda k L t F. - • .e 61 Ow'
(adeappopatssetae) 'rill=nwt.1mnrsrenrmiatiiir a .
minium _ 31 7t9C7 Hey be roan., jt r1;PM►1rr.
ran sad. k.
LONGITUDE_$j '07 35(, aemllam coin 10. WELL DIAGRAM Draw.detlod sash of the a dialled sketch of De1.th cm f ebockd *
L.tibid".DDgitde Source: 05) Topographic map firm showing tom(depth.depth and dancer of treat(ifeny)lecrailtiog
(Imams q(well seed be /ow on e LUGS ape to 'aed in die a.11,good Sr't twit dousing r''-- mq ad depths and
mocked to th itfmagrnce win GPSJ O'W_offll mmriebmot
4.FAmITY-Ty la d6e avian ass d...0 klieg.Gae<amta dIL / 1
(Yt�d.e4 Alp as amter a.ai waatafaaema dr.) 11. DATE WELL ARANDONfl n 771/6
FACILITY mR(depplinbk) 1DDHEREBY f'MATTES WELL WAS llABANDONED DI AO:ORDANCE
NAME OF FACILITY WITH ISA MAC 7C,VIELLC NMDCT13.1 STANDARDS.ANDIHATA COPY OF
STREETADDRISS ADDRESS iEmRDHAS WIN PROVIDFD7D DIE WELL OWNER.
at IX Stex Zip Cade OfCORTip®IVEZL WCfOR DATA .
ab.CXNTA PElt4Ot WHILOWNRR I' lJj/'Cr�// Li/I
NAME Purim Garza • ad:NATUREOr L-WwOWNIR �na WILL T 4...---.—....
own. ADID2E99 53 SPf- Q� (Ih.pawe al amL aindMts arks abr
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r roar s® furiTED Mitt )'mom WELL
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Ana wade-Phone number .
Submit.copy as lb.eweeraS the s151.alb là.DivIt.erwster Qaakey.as30dam • FrmGWW-3O .
AR=I.Srmatla Manz®x11617 Md Seedre Center—Radtke NC2709-161Z flat No.017)7I3-7011 at SUL Rev.SA
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