HomeMy WebLinkAboutWELL-09-2022-180379.TIF �.4atilo 140 Detmnmmp
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.�. Strtidivmon 1uICGEES POINT
;;Vi�� �a li trviraunewl Helth Drvuan. ' , , PINN' 481703301423
�s..t Y�I,PO Box 389,2SGoveroman Drive,Newton,NC,26658 4y I.OTa 8'•
" Ski Addis's:, 4227 MCGEE POINT RD,TERREL 'NC 28882 , ' '
Nan!on Pont PASCAL&CHRISTINE HELOU N
Properly son: Aces 0.69 _ I\
mncSns: - NC 150,Ron Shanills Ford Rd, Ron Hob.LN,Lon McGee Point
Owner/Authorized'Represenfative Acknowledgement of Permit Receipt
y I certify that I ant the owner or authorized agent(owner's authorization re uI ed)representing the owner of l'
the property described above.
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to As the property owner or authorized representative,I have received the above referenced
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'S.permit(s)as requested in the application for service RBPR-04-2022-40851,by the following method(s): e
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_ Received in Person
Facsimile Transmittal'(Return form with signature required)i Electronic Image Transmittal/E-mail (Return receipt required) -
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itAs tht.property owner or authorized representative I have re dviewe and understand the specific conditions - ti
.of the permit issued,,and further understand that all applicable regulatory'requirements specified under the -
North Carolina'Lail-and Rules for Sewage Treatment and Disposal Systems(15A NCAC 18A.1900),
and/or Well Constructionissuance Standards(15A NCAC 2C.0100), shall apply to the of this permit and r
the construction of the wastewater system and/or water supply well permitted.
Permit Issue Date:09/16/2022 11
Owner/Authorized'Representadve Signature 44J J11
a
Date .
IP/ytJel( 0t111
Documentation of Permlt(s)Transmittal i
' 4 -, (permit transmitted'by electronic or other means)
ofperson rson sendingpermit)
Permit transmitted by (nameIPePet l I
qe;
DatdTime `l/7Cl�� •Signature ;
Method:. ' Fax - Email US Mail Other r
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Owner's request to send by the above indicated method of transmittal in lieu of signature
We waittt"ttorhear from yortlease ttake a few moments tto complette our custtomer service survey att
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http://wwwsurveymonkey.cum/s/EHCusttomerServlce
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Imo• CATAWBA COUNTY Case# WELL-09-2022-180379
i~ t IR ,Z Public Health Department Subdivision MCGEES POINT
4, 'j Environmental Health Division PIN# 461703301423
74.7.
. PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 8
Site Address: 4227 MCGEE POINT RD,TERRELL NC 28682
Name on Permit: PASCAL&CHRISTINE HELOU
Property Size: Acres 0.69
Directions: NC 150, Ron Sherrills Ford Rd, R on Hob LN, L on McGee Point
WELL ABANDONMENT PERMIT
Well Type:
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.
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09/16/2022
Authorized State Agent Permit Issuance Date
9/16/2027
Permit Expiration Date
clips mtit 09/20/2022 12:55
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I. PIPE N08'01;3fi W i Qnadme r\ -
aEv:763.46.99.71
LOLL L-b 1-?-). -1 iO37/
FROM Tt7 jR�'.---' 30' REAR `ELEV:76
-�► LOT 8
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N G P4 - 60' - 5.3'
\010 �a •/1 W5 - 45' - 5.8'
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(Distributing Valve 30' F` T BM
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3 f • ,. g WELL ABANDONMENT RECORD
L7i I.< 3 North Carolina Department of Environment and Natural Resources.Division of Water Quality
i. ~°""~ . -- WELL CONTRACTOR CERTIFICATION#
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I.WELL CODRACCOR & WELL DETAILS: q 4
a S Q,J G I Ue� a Total Depth: ! ft Diameter Z Y ` .
Well Contractor(Individual)Name b.Water Level(Below Measuring Pomt): 3 7 R.
Measuring point is p{ Ct above land surface.
Well Contractor Company Name ,
STREET ADDRESS J 5 L — i , `? A" 6. CASING: Length Diameter
/Ye rll(1 -Gencl /V C Ds.- &7 a.Casing Depth Of known): ft. 2 7 in
City or Town State Zip Code b.Cuing Removed: ft. 2 V in.
(q[7)- '1e--;-?-' i ,9-[') ,^
Area code-Phone munbe f 7. DISINFECTION: '2-jail cos U) '&G h '
2.WELL LNFOIUKATION: (Amount of 65%-75%calcium hypochlorite used)
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SITE WELL ID it(if applicable) g. SEALING MATERIAL:
- "PATE WELL PERMTT 0(if applicable) Near Cement ,end Cernca(
Cement y0� lb. Cement_ lb.
COUNTY WELL PERMIT a(if applicable) • Water gal. Water gal.
DWQ or OTHER PERMIT I(if applicable) tn1onlk •
WELL USE(Circle applicable use): Monitoring Residential
Municipal/Public ladustrlat/Commerdal Agricultural Brntoltite Ib.
Recovery Injection Irrigation Type:Slurry_Pellets_
Other(list use) Warr. gal.
3.WELL LOCATION:�} I, Met material Ig eci G� t
COUNTY ( 1 4( S li ADRANGLE A/a ' 1 Gy
NEAREST TOWN: 7Cf/el ' j Amount i16 Yd5•
(SrrsevRoad Name,Number,Commtmity,Subdivitien,Lot No..Parcel,Zip Code) i 9. EXP IN METHOD OF EMPLACEMENT OF MATERIAL,:
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TOPOGRAPHIC/LAND SETTING: lJtr-1�►'fL t,^ iV I `1 S /1- C
Slope Valley Flat Ridge Other �-e e 4 Jer 2 ail KL5 ` ci
(Circle appropriate setting) • ( G41it' G[1I - I ipd1 e SAl.L7.
May be in degrees, I II 1 ✓✓
LATITUDE minutes,seconds.or in a
LONGITUDE _ decimal rennet / 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
Latitude/longitude source: GPS Topographic map form showing total depth,depth and diameter of screens(if any)remaining
(Location of well must be shown on a USGS topo map and in the well,gravel interval,intervals of casing perforations,and depths and
attached to this form((not wrung GPS) types of fill materials tun.
la.FACILITY-The name olds*business where tie well it located Complete 4a aodeb.
(If a residential well,skip 4a;complete 4b,well owner information only.) 11. DATE WELL ABANDONED /2 *9Co2 47
FACILITY ID#(if applicable) I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY /� WITH 1SA NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
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STREET A DRESj f( (7 / t 4Ac "-e t 0 la S RECORD HAS BEEN PROVIDED TO THE WELL OWNER_
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City br Town State p CodeCo SIGNATURE OF/TIED),CO CTOR DATE
<b.CONTACT PERSON/�/y/J�ry,,L OWNER: y ,, q/a 7/ateTU b!E J �(S SIGNATURE OEWELL OWNER ABANDONING THE WEIY D1TE
STREET ADD S 6 _ a G-i/' A,f•'t (The private well owner most be an individual who personally abandons his/her residential well
m accordance watt 1J',NCAC 2C.011 )
Yoe/re J nd et D 03 PRINTED NAME OF P RSON.A INC TKE WELL
City or Town State tp Code
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(q(7)- g5"e1.3 'a0
Area code-Phone number
Submit a copy to the owner and the origlul to the Division of Water Quality wkhl■30 days. Form GW-30
Atta:Information Management,1617 Mall Service Center—Raleigh,NC 2 7699-1 6 1 7, Phone No.(919)733-7015 est 56a. Rev.5/06
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