HomeMy WebLinkAboutWELL-08-2016-075540.TIF ti4A CATAWBA COUNTY Case#
,C�'ll z_ Public Health Department Subdivision LUTHER COWANS SHERF
< 7i?9•.by -' Environmental Health Division PIN# 462802667471
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-mak PO Box 389, 100-A Southwest Blvd,Newton,NC 28658 LO"I Jt 27 & PT 26
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NAME ON PERMIT: *OGDEN CONSTRUCTION, LLC, SHAUN, PO BOX 1281, DAVIDSON NC 28036-
Site Address: 9652 RIVIERA DR, SHERRILLS FORD NC 28673
Property Size: Square Feet: 31,798.80 Acres:0,73
Directions: 150 TO SHERRILLS FORD RD RIGHT ON ISLAND POINT LEFT ON RIVIERA DR
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 RBPR-06-2016-24168 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 well permitted.
•
Permit Issue Date: 08/10/2016
\ Owner/Authorized Representative Signature
T Date
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitte. by\ $ a I (name of person sending permit)
r ( � _
Signaturc�i � Q,O . �' Date/Time ` O @Qis
Method: Fax YEmail US Mail _ Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We want to hear from you. Please take a fevtlmoments to complete our customer service survey at:
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chpcnuit 08/10/2016 10158
CATAWBA COUNTY OP ni •; ® Calc# WELL-08-2016-075540
Public Health Department 'r . - Subdivision LUTHER COWANS SHERF
-- a •, • PIN#
< �t t' Environmental Health Division19 4 ti
PO Box 389, 100-A Southwest Blvd,Newton, NC 28658 �� '-� • O '' 462802667471
• LOTH 27 & PT 26
/842 s• -S. - it k r
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1%1:
NAME ON PERMIT: *OGDEN CONSTRUCTION, LLC, SHAUN, PO BOX 1281, DAVIDSON NC 28036-
Site Address: 9652 RIVIERA DR, SHERRILLS FORD NC 28673
Property Size: Square Feet: 31,798.80 Acres:0.73
Directions: 150 TO SHERRILLS FORD RD RIGHT ON ISLAND POINT LEFT ON RIVIERA DR
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 08/10/2016
ISSUED BY PERMIT ISSUANCE DATE
chpemiit 08/10/2016 11:02
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t D is DON ALLEN & A9SOC1 ATER , P. A
'/Ia+ "Stn ce 1971'
Commercial • Residential • Mortgage Surveys • Multi-Family
G Construction Stoking • Subdivision Docign • Topographical
131 Cresslake Park Drive - SNite 102 • Mooresville • NC • 28117
(704) 654-7029' (704) 664-8041 FOR
I, certify that, this map was drawn under my oupervision from an actual
survey made under my supervision recorded in deed book___, page , and/or
plot book 12 • page 102 • that the ratio of precision is 1 :10,000, that this map
was prepared in accordance with the General Statutes of North Carolina Chapter 89C.
my hand and seal on the 22 . day ofJAN[— / —• .w
A.D. 20 16 �--•'%�ra...ea?" ''..
WILLIAM M. AEI: •.•A • �'a"�v
'' SEAL -
CURVE TABLE L3499
CHORD .. 4e.
CURVE RADIUS LENGTH BEARING I'�z'�d'O E;P�=c
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1) THIS PROPERTY MAY BE 9Jn.CCT TO 671 (�
ANY EASDSENT AND/OR WQNTs-6-why V, c°
OF RECORD. Der CHH
]) AREA COMPUTED BY THE COORDINATE • 1•
1112.piPE ) EYI SING 780' k 701 CONTOUR CtEV- Adx-V
RIVIERA DR. 5AT1ON BASED ON LAKE NORMAN LAKE
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6) N0 GM MONaWENT rOUNO AMON
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SCALE IN IN FEEL PLOT PLAN SURVEY
or
9652 RIVIERA DR .
LOT 211,67 A PORRON OT 26 WINER COWANSSHCRRILI RPAL
SCALE 1• a 50' MOUNTAIN CREEK TWSP.. CATAWBA CO.. N.C. naD mac'
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ACQUIRED BY: oc me
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no09/08/2016 15:56 7048924705 EKWELLDRILLING PAGE 01
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WELL ABANDONMENT RECORD ,_This form can be u
sed fpr smgie or multiple wells For imernrl Use ONLY;
I.Well Contractor information:
Alfred Kiesling Jr WE i AeANnra°'ANT DFerwlLe
Well Contractor Name(or well owner ,_ 7o,Number of wells bean a
personally abandoning well on his/her prppeay` For an In r g bondoned:��`y
3266-A a p' donmean m 'intent[ avpp n.fl. (INGY with (he
aroma.
ean.vnrruen'abandanmrni.you can rvbnur one fa r^
NC well Contractor Cenii talion Kumpe. 7b.Approximate volume of water remaii
nng in well(s):
B & K Well Drilling Inc. (pl./
FOR WATER SUPPLY WELLS ONLY:
Company Namc qq//
2.well Construction Permit d:r.atJ)/G /1 it.Type of disinfectant used:_ C.k7 br l i
Liar all oppnaanre well w^11 C— __-�.-
prPe r/i r.!aunty,Gore ✓rel lnfeulon,err/Jrnown
7d.Amount of disinfectant used: +4-CYf
3.Well Use(check well use):
Water Supply Well:
7e.Sealing materials used(cheek all that apply)•
DAgriculmral DMunicipal/Public inicid Cement Grout Fn.—
❑Geothermal(Heating/Cooling Supply) aftesidential Water Supply lie) '-� Sand Cement Grout 0 DryClaI Dry„eraI:mt •
❑Industrial/Commercial ❑Residential
CIrri ation Water Supply(shared) 0 Concrete Grout t] L7;ill Cutting,g 0 Specialty Grout 0 Gravel
Non-Water Supply Well:
xovm
0 Bento,oite Slurry
❑Monitoring DRa Other(explain under 7I0
Infection Well: 7f. For each material selected above,proyideamount of materials used:.
DAquifer Recharge OGmoundwater Remediation 2 I1E L
❑Aquifer Storage and Recovery OSaliniuy Barrier rr• ,��^Rsg "'Y1^ ���
❑Aquifer Test OStortnwater Drainage 1 ��-lAn/ L-e/k,�v -f
°Experimental Technology ❑Subsidence Control (�
7g.Provide a betcfdescription of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return)) COther(explain under 7g) -
a
4.Date well(s)abandoned' 51e //4
6a,Well location: ^-----....._
O din 9.- C 4-f.iLL.4f0”
Fad/to/Go/nor Name Each, Ito(tripoli:able) S.Certification:
5'G..S"r I
Vie tlk Sega I(atg,i 2-15--. j
Physical Ad&cee.City,and Zip Sigmnae t ertinciWcIL Corirracto.r or W --_ one
0.f es..4Ler y 2s-a,212_ 7hy signing this form 7 hereby cei fy Item i the well(s) was (vete) abandoned in
County Parcel taentifieaiion No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 tr'e/l Conmucnon Standards
and that a tory of this record hat been provided la the well owner. ,
5b.Latitude and longitude in degrees/minures/seconds or decimal degrees:
rifwell field one ladlong is sufficing 9.Site diagram or Si Officinal well details:
You may use the back of this page to provide additional well silo details or well
N W abandonment details. You may also attach additional pages if necessary
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED $TIBMITTAL INSTRUCTIONS
Attach well conetrurtwn record(s)rf available. Far mdriple inlet don n tearer,cuppl'
well.ONLY rash the come como-urrion ahmdonmov ym.can'about one farm I Oa. For Afl Wells: Submit this form within 30 days of completion of well
6e..Well ITP): abandonment to the following:
Division of Water Resources,Information Processing Unit.
ja 1617 Mail Service Center,Raleigh,NC 27699-1617
bb.Total well depthil v S7 (R)
I Ob. For Injection t h : In addition to sending the form to the address in IOs
^�'�t above. also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: O%-- (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program.
6d.Water level below ground surface: MO 1636 Mail Service Center,Raleigh,NC-2276994636
10c, For Water Supply 4c Luiectiun Weill: In addition to sending the form to
6e.Outer casing length(if known): (R-) the address(es) above. also submit one copy of this form within .30 days of
completion of well abandonment to the cramy health department of the county
where abandoned.
6L Inner casing/tubing length(ifknown): (ft.)
•
6g.Screen length(if(mown): (R.)
Form GW-30 Nosh Carolina Department of Enviremnent and Natural Rescwcea-Division of W ner Resource: Re,,,cd August 5013