HomeMy WebLinkAboutWELL-05-2022-171033.TIF CATAWBA COUNTY Case# WELL-05-2022-171033
•C
Public Health Department Subdivision
) Environmental Health Division PIN# 269702896332
In PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1
sw
Site Address: 4313 PLATEAU RD, NEWTON NC 28658
Name on Permit: CECIL STONE
Property Size: Acres 0.92
Directions: Hwy 10 W, left Plateau Rd, on right just past Scronce Rd
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.
37dret- 6#17
05/09/2022
Authorized State Agent Permit Issuance Date
5/9/2027
Permit Expiration Date
chpciinil 05/10/2022 09:43
Catawba County Environmental Health
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Parcel: 269702896332, 4313 PLATEAU RD 1 in=50ft
NEWTON, 28658
This map/report product was prepared from the Catawba County,NC Geoepatlal information Services. Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained on this map or data on this report.Catawba County promotes and recommends
the independent verification of any data contained on this map/report product by the user.The County of Catawba,its employees,agents,and
personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct,Indirect or consequential which arises or may
arise from this map/report product or the use thereof by any person or entity.
Copyright 2021 Catawba County NC
05/09/2022
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1-3-- Sr V Dy‘C-12------, 7a.For Geoprabe/DPT or Closed•Loop Geothermal Wells having the same
Well Contractor Name r well owner personally abandoning wall on Mather property) well construction/depth,only I OW-30 Is needed. Indicate TOTAL NUMBER of
--).-: ._,,C)1 Li
Pt wells abandoned:
NC Well Contractor Certification Number lm'lb,Approzato volume of water remaining In well(s): So (gal.)
Lscy('p1(�,���u,1 }ry',1�,` 'l y VlF ty? FOR WATER SUPPLY WELLS ONLY:
Coroparty aY,rte� ,j1n C i\°V 1 "73Clo
1 I 7e Type of disinfectant osed: p `
2.Well Construction Permit II; 1ArJ,l--o-C 2-0 L,'2 1�!t3
Lslall applicable owl!confusional,permits(l.e,U)C,County,State,Parlance,etc.)(Thwart
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Weil: 7e.Sealing materials used(check all that apply):
°Agricultural ❑MunicipaVRtblic C Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(ainglo) 0 Sand Cement Grout 0 Dry Clay
❑lnduatriallCommercial OResldentinl Water Supply(shared) X Concrete Grout 0 Drill Cuttings
O(nigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well; 0 Bentonito Slurry 0 Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well; 7E For each material selected above,provide amount of materials used:
OAqulfer Recharge DOroundwata Remedislim SAYS et.Grovel 4
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimeatal Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
°Geothermal(Closed Loop) OTracer c N, • 1 L O'1 '4v e' Ll}/�1T1 Pv 17), AYJ
°Geothermal(Heating/Cooling Return) °Other(explain under 7g)
6 - �� -zz Qt�� Saba wA,p. 7'370 ;r Wall .---- rN
4.Date wells)abandoned: Pb Asi t i2-Voelk- }"4j(1� r 1:"A./.� 1 n. �l C-'1,
Se,Well!Talon:
Gt.c..►I` �-ki� ( 11o5-zo-u 17/033 ,`�
Facility/Owner Name Facility lDlI(if applicable) 8.Certification:
y 313 f'10,'1-c__ ,.,,RA, Awft,r, Nc,2Vgs8 • • 6_7' Z-1--
Physical Address,City,andd Zip / � Signature of Certified II C.onbaclor or Well Owner Dale
C-r-ic-u`DC/,l..ouad� �b 9i/6Z104 33 By signing this form, ! relubr cerf(j'that the well(s) was(mere)abandoned in
Cowry Parcel Identification No.(PIN) accordance with!SA NCAC 01C.0100 or 1C.0100 Well Construction Standards
and that a copy ojthts record has been provided to the well ouster.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one hi/tong is sufficient) 11 9.Site diagram or addiNonal well details:
O d 5/ 1 C 1l 0% i �11 2-1 W You may use the bark of this page to provide additional well she details or well
J J N lJ U 1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S1 BEING ABANDONED SUBMITTAL INSTRUCTIONS
Artoch Melt constriction record(s)iatailable.For multiple Infection or nun-ata/ersupp(y wets
ONLY with the same ceratructtordabandonntent,you con submit on forcer,
�/ 10a.For MI Wells: Submit this form within 30 days of completion of well
6a.Well ID#:19.' N 17 1 633 abandonment to the following:
i./r 1 ,t Division of Water Resources,Information Processing Unit,
6b.Total well depth: (�1 b (It-) 1617 Mall Service Center,Raleigh,NC 27699.1617
�'1 11 lob.For infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: •"I am) abandonment
also submit one copy of this form within 30 days of completion of welt
abandonment to the following:
II
6d.Water level below ground surface: IJ 9 ifs.) Division of Water Resources,Underground Injection Control Program,
�
1636 Mali Service Center,Raleigh,NC 27699-1636
6c,Outer casing length(If(mown): I VI!i] (n.) 10c,For Water Supply dt Injectton Welk: In addition to sending the loon to the
addreas(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
6E Inner easing/tubing length(If known): Al/ (ft.) abandoned.
6g.Screen length(If known): /\1! /T (It)
Fora GW-30 North Crvolina Department of Environmental QtmCny-Division of Water Resources Revised 2-22-20t6