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Home My WebLink AboutWELL-11-2022-185183.tif C m� CATAWBA COUNTY (...._-t. Public Health Department Subdivision WESTON Qam�s Environmental Health Division PINS 266901455525 a�yy PO Box 389,25 Government Drive.Newton.NC 28658 LOTS 14 it■ Y✓ Sits Address: 1827 MESA DR,VALE NC 28168 Name on Permit: 'CLAYTON HOMES OF CONOVER Property Size: Acres 1.200 Directions: R on NC 10 Hwy W, R on Providence Church Rd, L on Old Shelby Rd, R on 8rittain Rd, L on Mesa Dr Owner/Authorized Representative Acknowledgement of Permit Receipt 1.IV I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of the property described above. t, Yu`- As the property owner or authorized representative,1 have received the above referenced permit(s)as requested in the application for service RBPR-03-2022-40377,by the following method(s): Received in Person _ Facsimile Transmittal(Return form with signature required) Ni Electronic Image Transmittal/E-mail (Return receipt required) t As the property owner or authorized representative I have reviewed and understand the specific conditions r 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(I5A 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: 11/28/2022 i Owner/Authorized Representative Signature Date //-cZ - - / Documentation of Permit(s)Transmittal (permit transmitted by electronic or other means) Permit transmitted by (name of person sending permit) Signature E. Date/Time Ii tZ(Iz Method: Fax i 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 yolPlease ttake a few momentts tto complette our custtomer service survey att http://www.surveymonkey.com/s/EHCusttomerService MAR t Vauk4 e&U/i /g► 'E,n1 l'I.,h'llllll 1 V l t/28/2022 16 32 +� CATAWBA COUNTY Case IIWELL-I I-2022-185183 14 .�, ,� Public Health Department Subdivision WESTON , ' < Environmental Health Division PIN# 266901454499 PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 13 8• w Site Address: 1835 MESA DR,VALE NC 28168 Name on Permit: *CLAYTON HOMES OF CONOVER Property Size: Acres 1.12 Directions: R on NC 10 Hwy W, R on Providence Church Rd, L on Old Shelby Rd, R on Brittain Rd, L on Mesa Dr WELL ABANDONMENT PERMIT Well Type: Bored 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. 311/W4&. 6,7(A°- 11/28/2022 Authorized State Agent Permit Issuance Dale 11/28/2027 Permit Expiration Date cliprrmit 11/28/2022 16:34 vlau -1/-)0))-1 Si 2- \NJetA ' i( -20ZZ- /Ssi •3 Catawba County Environmental Health 1 '1 I I I I I I I I 140., I I o� L , I I SO' a VA 1 .1827 \y So :,....)57 r. I 1�� O 39j�BII_ I$ I1 IJlao� a183s - 1j� Qom- I o10 1 a �y� I --�-1cv co 1 go(c b Well '40, I g 345.46 • I ts be a6Acion4C/ 1 1 I w I I d co 8 .1841 to I 115.49 ir- I I I I 1 64.54 Parcel:266901454499, 1835 MESA DR VALE, 18n=50ft 28168 Tia mapMpoA productwas prepared the Catawba Coup b.MC Geoe9attal In IorTuUon Services. Catawba County has made aubstanWl snorts to ensure the ecnxacy of location and labeling Inlormatbn contained on Ws map or data on thta report.Catawba County promotes end recommends pl.Independent verification of any data contained on thls mapheport product by the user.The County of Catawba,Its emptoyeea,agents,and personnel,dNclain,and shag not be held gable for any and all dimple.bee or'lability,whether direct,Indirect or consequential vouch arose or may Mae from this rnapinport product or the use thereof by any person or entity. Copyrfphl 2021 Catawba Canty NC 04r25P2022 WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS 'Tef r 1 TS care nck 7a.For GeoprobeMPT or Closed-Loop Geothermal Wells having the same Well Cofactor Aram(or well owner personatly abandoning well on hieber property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of 2-C) 4 _.n wells abandoned: --- ---._ t^ NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):5 0 V (gaL) z•_(Y .)-c-r-c 1-•oe..—.W e lu t` .1 t N l YjA,roliq FOR WATER SUPPLY WELLS ONLY: Company f J �0 3 7c_Type of disinfectant used: , 3 r�t; 1 G tr; C-- 1.Well Construction Permit fi: 1 4-0�Z�•�� t 1 �— List all applicable well conuructton permits(Le.U/C County,State Variance,etc)if bto,„r r 7d.Amount of disinfectant used: i Z -�-r 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): °Agriculhual ❑Mrmicipal/Public 0 Neat Cement Grout Q Bentonite Chips or Pellets °Geothermal(Heating/Cooling Supply) 3412esidential Water Supply(single) 0 Sand Cement Grout lit Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) lit1 Concrete Grout 0 Drill Cuttings ❑Irrigation ❑ Specialty Grout 0 Gravel Non-Water Supply Well: C Bentonite Shiny 0 Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7L For each material selected above,provide amount of materialsused: ❑Aquifer Recharge ❑Groundwater Remediation Ucn v` L�C' Ca v�r.c�f C i ❑Aquifer Storage and Recovery °Salinity Barrier i ��e ❑Aquifer Test ❑Stormwater Drainage QFxperimental Technology QSttbsidettce Control 7g_Provide a brief description of the abandonmentt pro-cedur e: ❑Geothermal(Closed Loop) ❑Tracer Cv.� ( i l G gel�is� \Sr�'�^` 1 sy. Piim i�2�tn� OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Q t _ CI.1er;,(z-- .t,(, \ I( 1 kfaAwill 1.3.. 4.Date well(s)abandoned: / L.- )Z •2Z r,�\ I i //�� 4.) f 1 t?4 5a_Well location: 1 1 r lu.l�-�� Co1 r\c.tt,4 6-rt� r. C i e t:+p,�', D rvti'c CkG neV.Cr''1 IC)1-I S SVarg FacilitylOwiter Name Facility ID#(if applicable) 8.Certification: /C-415 (C J 11 i\ J CJ 1\1tC -2'S1 C V .. c2+"M�'&&'-' ' tiV`f�7r I . l ZL- Physical Address.City.and Zip eL77 L l�} Signature ofcrtised Well Contractor or Well Owner Date l;( ., --‹. N c.,ZO I a -2 i O I " S S 5 By signing this form, I hereby certif_r that the well(s) was(were) abandoned in County Parcel Identification No.(PIN) accordance with JSA NCAC 02C.0100 or 2C.0200 Well Constntction Standards and that a copy of this record has been provided to the well comer 5k Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one bong is sufficient) 9.Site diagram or additional well details: 0- t) - .1 ;l PI`d C Cj�'ti l _2. ll 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 if necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)if available. hoc multiple injection or non-water supply wells ONLY with the same constnrctiotJabondopment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: i t.}Pi Z�:I '-Zr> abandonment to the following: i Division of Water Resources,Information Processing Unit, -7 6b.Total well depth: V (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617 tt 10b.For Injection Wells: In addition to sending the form to the address in IOa 6c Borehole diameter: 2-4 (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 / U 1 (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e_Outer casing length(if known): q D (ft.) 10c.For Water Supply&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 6f.Inner casing/tubing length(if known): 0 (f(.) abandoned. 6g.Screen length(if known): C. (ft)