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Home My WebLink AboutWELL-02-2021-145678.tif .$• . CATAWBA COUNTY P_Le,k11 Se 11) Case#� � , i� �� WELL-02-2021-145678 " .4 Public Health Department �']23 N Subdivision d .� Environmental Health Division p PIN# 374207680515 'C PO Box 389,25 Government Dr ,Newton,NC 28658 1 7, sM (828)465-8270 FAX(828) 5-8276 TDD(828)465-8200 LOT# Site Address: , CONOVER NC 28613 Name on Permit: ROCKWATER WELL&PUMP Property Size: Acres 39.32 Directions: 140 N take exit 132(Hwy 16)turn left on Hwy 16,turn right on Hwy 16, property on 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. V As the property owner or authorized representative, I have received the above referenced 1'permit(s)as requested in the application for service EHPR-02-2021-36776, by the following method(s): _ Received in Person Facsimile Transmittal (Return form with signature required) V— Iectronic 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(15 A 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: 02/18/2021 / Owner/Authorized Representative Signature Date Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by,,T) fl flI i f ( (name of person sending permit) Signature Date/Time i j (c-. (-I1 �� Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature acknowledges the conditions and statements above. We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att http://www.surveymonkey.com/s/EHCusttomerService ro ' i . J_rin‘-A77.L.I . • �L g �"1�:�I I �tm ,._, f eltpernut 02/19/202I 09:10 ft I 111 L-5 Ci of (01W tir CATAWBA COUNTY t1 p dY�S Sd Case# WELL-02-2021-145678 Public Health Department ��U151'01 S I� cka Subdivision Environmental Health Division n} NC, 1 PIN# 374207680515 Y PO Box 389,25 Government Drive,Newton,NC 28658 i 7 2-3 - `�" / su (828)465-8270 FAX(828)465-8276 TDD(828)465-8200 LOT# Site Address: 1621 14-Ng 1-S4IWY, CONOVER NC 28613 Name on Permit: ROCKWATER WELL&PUMP E KW- O ^ O0a I _ P1 Property Size: Acres 39.32 Directions: 140 N take exit 132(Hwy 16)turn left on Hwy 16, turn right on Hwy 16, property on left WELL ABANDONMENT PERMIT Well Type: Dug Wells shall be abandoned in accordance with state regulations: Article 15A North Carolina Administrative Code Subchapter 2C The Well Abandonment Report must be submitted to the Catawba County Environmental Health within 30 days upon completion of a well abandonment. Well contractor must schedule well abandonment inspection with Catawba County Environmental Health. 02/18/2021 Authorized State Agent Permit Issuance Date 2/18/2026 Permit Expiration Date elapermit 02/19/2021 09:10 WELL ABANDONMENT RECORD For Internal Use ONLY I.Well Contractor Information: // WELL ABANDONMENT DETAILS f l/ ca_e l 1q 18k-,U 0/L" 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on histher property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: V-a/Oi 0 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) ) Dehi- hrG d I/ ('�)d J l i/z,/`_) FOR WATER SUPPLY WELLS ONLY: Company Name / 0 f �/� ' �} t}��y ( )j ) Q7c.Type of disinfectant used: 2.Well Construction Permit ty:tNC/I/I - (1,)�(90 ( '/` ,,5 t7 Ct tar,,ll opplrenhle well construction f erwnt.s(ue. tilt'.Courtly,Slate,Variance,etc•./,lknown 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(cheek all that apply): ❑Agricultural ❑Municipal/Public ZNeat Cement Grout 0 Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) Rikrgidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay Olndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings 0 Irrigation 0 Specialty Grout 0 Gravel Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation ;t i.1 t SS C, - Po., -jt ❑Aquifer Storage and Recovery ❑Salinity Barrier " ❑Aquifer Test ❑Storrnwater Drainage OGxperimental Technology OSubsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) OTracer �^ 1 ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _ e4,ietit L ipeee..- {-+ 11 eci ,, �a y o +t's t V/,a f✓l Gt>n C.J c.3 !.a t VG....-. c c < - 4.Date well(s)abandoned: , y' / 1) (-1 5a.Well location: /V■ 1� fb ,l?l/e./i11.iIft 7u,t- C' r r FacihiyiOwner Name Facility IDA ltfapplicable) 8.Certification: /'Vic)j f) i7C /1' 11u n/Vitlt ' c E'l f/L3 fi�,� ,1,, _: 2/a/ , Physical Address,City.and Zip Signature of Certified Well Contractor or Well Owner Dale £?e-in tri/'a.r"`- 37 7 15 By signing this form. /hereby certify that the well(s) was (were)abandoned in County Parcel tdcnrifcarinn No.(PIN) accordance with 154 NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (dwell field,one lap/long is sufficient) 9.Site diagram or additional well details: 35 • t'31 96i N — t e 1, 243/5.sj 7 W You may use the back of this page to provide additional well site details or well abandonment details. You may also attach additional pages it-necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction,ee,rtl(.cyifr,rw/ahle. For multiple Injection ar non-water.cnpph•wells OA7.I'with the s ine cunstruc,ran•ahaudn,men,,,you can srdrntO one fowl. ]Oa. For All Wells; Submit this form within 30 days of completion of well 6a.Well MN: abandonment to the following: t Division of Water Resources,Information Processing Unit, 6b.Total well depth: 2 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 t 10b. For Injection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: `, (in.) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: 6d.Water level below ground surface: 0 (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): (fit,) 10c.For Water Sunnlv&Injection Wells: In addition to sending the form to the address(es)above,also submit one copy of this form within 30 days of completion of well abandonment to the county health department of the county where 61.Inner casing/tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): (ft.) Font Gw:to North Carolina Department of Environmental Quality-Division of Water Resources Res ised 2.22.2016 -.,,,..."... ..,--.1. / „-- ,..-- ,---". ....0*--. ........""'s . I'N 0 ri ".. \,.... , ,-, . .