HomeMy WebLinkAboutEHPR-06-2016-24003.TIF +.'4tt ; M K
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s " ° CATAWBA COUNTY Case it EHPR-06-2016-24003
cifv Public Health Department'f i P Subdivision
-f5`� „ Environmental Health Division PIN#
371107792430
�Z4 N PO Box 389, 100-A Southwest Blvd,Newton,NC 28658
CAME ON PERMIT: aANDUJAR CONSTRUCTION INC.
(KENNETH ANDUJAR),3013 GRIFFITH ST,CHARLOTTE NC 28203
*Andujar Construction, Inc. ( Kenneth Andujar)
Site Address: 2115 HWY 70 SE,HICKORY NC 28602
Property Size: Square Feet 63,162.00 Acres 1.450
Directions: Hwy 70 SE,Across from Academy Sports
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„ a{j WELL ABANDONMENT RECORD
i If'�y})/Y North Carolina Department of Environment and Natural Resources-Div�isioon of Water Quality
WELL CONTRACTOR CERTIFICATION.# 2/ 4 6 TY
I.WELL yONTR/ACC_TOR`l/) }/� S WELLDETAIILSf _
7 I {/ ((((�,�, c ("jry�!Ce a.Total Oeplh: �� -0. Diameter.
fl e kto &lig / s, �s b:Water Level(Below!Autumn Point): ,__a.4Q
/ ( % /t,C, Measuring point is ft,above land eorfaa.
Well Contactor Campo was v�/�, /'
S'rR ADDRESS // �/C - ' r.�n�npp/_ . G CASING: Length Diiiaameter
lLoto to
pea •Casing Dcph(if known): (fa R. V m.
City rTo State Z C'Code b.Casing Removed: It it
3a9 °erg 1 C`1,0
Area code-
Phone number 7, � DISINFECTION: �
2.WELL INFORMATION: fiOCCunt of 63%..75%calcium hypoehlorhe used)
SITE WELL IDA(if applicable) S. SEALING MATERIAL:
STATE WELL PERMIT R(if applicable) Not Cement $god Cement
COUNTY WELL PERMIT a(if applkable)05 t9-'/V V73/o 9 Cement lb. Cement Ib.Water gal.. Wets. yet.
DWQ or OTHER PERMIT a(if applicable) gealoniI
0 WELL USE(Circle applicable use): Monitoring Residential Btdk lb.
MuoicipaUPublk InduatriaLC cnm
ommercial Agricultural Bento Shiny_Pellets
Recovery Injection Irrigation. Water
Other(list use)
Other
3.WELL LOCAT ON:
COUNTY ',S 4 ..*.•rl'. aRANGLE NAME Typo material �6d �If/'.LL
NEAREST a . . •. die r Amount 7,44 j
A, jf. .1r4-6Pi,frl.
AL(SaatveedNUro. ..,Caron .Snbdiviaiun,lotto-Para Zip Cade) 9. EXPLAIN METRO F EMPLACE MATE R
TOPOGRAPHIC!V SETTING: Da1 yes A le 1114-.t Ito
Slope Valley PI Ridge Other ('_,(/-
(Circle appmpnate Krems)
LATITUDE Malta be is degrees.
mewtr•.ecmu,or to a
LO$CrflDE.__ dent fan e 10. WELL DIAGRAM:Draw a detailed sketch of the well on Ube bark of the
Latitude/longitude source: GPS Topographic map form shoving total depth.depth and diaSter ofacretos(if my)temalning
(Location of well mutt be shown on a USGS topo mop and in the well,putt Interval,intervals afasing perforadooe,and depths and
attached to this form#nor using UPS.) types of fill materials used.
4t FACILITY.The now atPetilen what the nNl is laeand.Cowley 4.andel,. (— J
(4a redone well.skip4;coagkte4h well inkmwim ady.) I . DATE WELL ABANDONED „Tic*, (I ` 6
FACILITY ID Of applicable) I Do HEREBY CERTIFY THAT TIIIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY Wren ISANCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OP
S2REE7ADDRfSS. THIS RECORD HAS BEEN PROVmm TO THE WWI/ELL OWNER.
City Town State TO 6-4 AT
tyro Zip Code NANRE OF RTIFIg WEI.L.CONTRAC R DATH
4b.CONTACT PERSONIWEL OWN R:
NAME eta A- e • ' IIi0 , Fed e/ SIGNATURE OF PRIVATE WELL OWNERABANDONNO THE WELL DATE
STREET ADDRESS_ Y i .\ T' ObL ehw welt owoa inn be a iaw4ml who gikallxehendece eh9+vmidawt wee
STREET, e 0 S b andante wit 15A NCAC 2C.0113.)
City or Town e SWe d Zry°Coda�"O� PRINTEDNAME OFPERSONAHANDONINO THEWRLL
L). ecaa - /ooh
ae a-Pico enum
Submit a copy to the owner and the original to the Division of Water Quality within 30 days, Fm/IOW-30
Attn:Information Management,1617 Mail Service Center-Rakigh,NC 37699-1617, Phone No.(919)733-1013 ext 368. Rev.5106
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