HomeMy WebLinkAboutWELL-09-2022-181126.TIF I.
' 4T� CATAWBA COUNTY Case ii
�r`a W'LLI:09-2022-I R 1126
i' - Public Health Department Subdivision
Pit , If .v....mourner menial Health Division PINt 462705089729
'br/• � PO Box 389.25 Government Drive.Newton,NC 28658 LOTH 13
' Site Address: 9101 CLEMENT CIR.TERRELL NC 28682
Name on Permit: 'BLUEFIELD BUILDERS;LLC
Name on Permit: KEITH MOYE
Property Size: Acres 0.63
Directions: E NC 150 hwy right Greenwood Rd left Clement Cir property on right toward end
Owner/Authorized Representative Acknowledgement of Permit Receipt
certify that lam the owner or authorized agent(owner's authorization required)representing the owner of
property
described above.
/(7.3\ s the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-09-2022-42349,by the following method(s):
Received in Person
___ Facsimile Transmittal(Return form with signature required)
T Electronic Image Transmittal/E-mail (Return receipt required)
ra_
kCAs 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(1 5A NCAC 18A.1900),
and/or Well Construction Standards(I SA 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:09/26/2022
Owner/Authorized Representative Signature
Date 1013 y as
Documentation of Penn it(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Ci.a Date/Time /1301))
Method: Fax 'r Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yoa.Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/ERCusttomerServIce
4r
dgaynn1 09/26/2022 M0
_8% CATAWBA COUNTY Case# WELL-09-2022-181126
f� t MIL L Public Health Department Subdivision
d `- Environmental Health Division PIN# 462705089729
PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 13
I. • . ,Y
Site Address: 9101 CLEMENT CIR,TERRELL NC 28682
Name on Permit: `BLUEFIELD BUILDERS, LLC
Name on Permit: KEITH MOPE
Property Size: Acres 0.63
Directions: E NC 150 hwy right Greenwood Rd left Clement Cir property on right toward end
WELL ABANDONMENT PERMIT
Well Type: Unknown
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.
aihaleite PE';k;4i 09/26/2022
Authorized State Agent Permit Issuance Date
9/26/2027
Permit Expiration Date
ehpenuit 09/26/2022 15:10
WELL ABANDONMENT RECORD
For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
KEN JOHNSON
7Well Contractor Name(or well owner personally abandoning well on his/her property) well1consor sttru construction/depth,pth,only 1 GW-30 iobe/DPT or s needed. Indicate TOTells AL NUMBving the ER of
2608A wells abandoned:__
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
AIR DRILLING INC
FOR WATER SUPPLY\VF,1,LS ONLY:
Company Name
09-202_2-181126 7c.Type of disinfectant used: HTH
2.Well Construction Permit it;
hilt all applicable well construction permits(i.c.C'l( County,State,Parlance,etc.)if'known 2 C U PS
7d.Amount of disinfectant used: l�
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricttltura]
❑Municipal/Public 0 Neat Cement Grout Ll Bentonite Chips or Pellets
UGeothennal(Ileating/Cooling Supply) ®Residential Water Supply(single) U Sand Cement Grout °Dry Clay
❑Industrial/Commcrcial ❑Residential Water Supply(shared) 0 Concrete Grout ill Drill Cuttings
Ghtigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well:
❑Bentonite Shiny ❑Other(explain under 7g)
LlMonitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Rcmediation 50 BAGS
!TAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
UExperimental Technology °Subsidence Control
❑Gcothcrmal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Heating/CoolingReturn) ❑Other(explain under 7g) POURED 50 BAGS BENTONITE CHIPS
4.Date wells)abandoned: 1 1— 18-2ry 022
Sa.Well location:
BLUEFiELD BUILDERS
Facility/Owner Name Facility IN(if applicable) er 'cation;
9101 CLEMENTS CIRCLE,TERRELL,N.C. 28682 11-8-2022
Physical Address,City,and Zip
Signature of Certified II Contractor or Well Owner Date
CATAWBA 462705089729
By signing this Arm, I hereby cerrift that the tee//(s) was(ner•e)abandoned in
County Parcel Identification No.(PIN) accordance with 15A n'CAC 02C.0/00 or 2C.0200 Well C.croslruCliv,,Standards.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record hue been provided to the well owner.
(if well field,one tat/long is sufficient)
9.Site diagram or additional well details:
35o 35.952 IN80u 56.923 \� You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONS'CRUCTiON DETAILS OF WELL(S)BEiNG ABANDONED
.leach wellconstroc(ionrrrurdts)Javailable. Formaltipleinjectionortan-nwtcrslippt,•oto•,• SUBMITTAL INSTRUCTIONS
ONLY with the same constructiwt!ahandonme•nt•you c•an.submit one Arm.
10a. For All Wells: Submit this form within 30 days of completion of welt
6a.Well 1Dit: abandonment to the following:
Division of Water Resources,information Processing Unit,
61).'1'otal well depth: 125 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob. For Injection Wells: In addition to sending the font to the address in IOa
Lr.Borehole diameter: 6 (ire,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
(ft.) Division of Water Resources,Underground injection Control Program,
6d.Water level below ground surface:
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the loon to the
6e.Outer casing length(if known): (ft.)
address(cs)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.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016