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CATAWBA COUNTY Case S WELL-12-2022-185512
Ni flak.�. Public Health Department Subdivision
;4.1 }s Environmental Health Division PINS 378110267296
, PO Box 389,25 Government Drive,Ncv,ton,NC 28658 LOPS
Site Address: 5268 HUDSON CHAPEL RD,CATAWBA NC 28609
Name on Ptrmlt: TINA LITTLE
Property Um: Acres 55.06
Directions: NC 10,right onto Rosenwald School Dr,right onto 5th Avenue Ct SW,left onto 4th St SW
Owner/Authorized Representative Acknowledgement of Permit Receipt
xTL I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
( the property described above.
TL_As the property owner or authorized representative,I have received the above referenced
permit(s)as requested in the application for service EHPR-11-2022-42888,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
� Electronic Image Transmittal/E-mail (Return receipt required)
.?(./L.-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(I5A 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:12/02/2022
�q Owner/Authorized Representative Signature Y,ea,- �L�ib-z-
- f Date /2//8(/2 0 zZ_
Documentation of Permits)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date/Time I)161(7Z
Method: _Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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fig' CATAWBA COUNTY Case# WELL-01-2023-187000
.L7 .t. . Public Health Department Subdivision
Q . "� Environmental Health Division PIN# 378110267296
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
/ 2 s�
Site Address: 5268 HUDSON CHAPEL RD,CATAWBA NC 28609
Name on Permit: TINA LITTLE
Property Size: Acres 55.06
Directions: NC 10, right onto Rosenwald School Dr,right onto 5th Avenue Ct SW, left onto 4th St SW
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.
PERMIT CONDITIONS
The well is to be abandoned in accordance with 15A NCAC 02C.0113. In particular, please note the following:
The well must be disinfected prior to being filled,as per 15A NCAC 02C.0111.
The well shall be filled to the top of the remaining casing with grout,dry clay,or material excavated during
construction of the well.
A 6"thick concrete grout plug shall be placed on top of the remaining casing such that it covers the entire excavated
area above the top of the casing extending 12 inches or greater outside the well casing.
The remainder of the well above the concrete plug shall be filled with grout or soil.
461 4—i pr;ktRsl 01/04/2023
Authorized State Agent Permit Issuance Date
1/4/2028
Permit Expiration Date
chpermii 01/04/2023 10:37
WRI - b(- ) ;3 - I$ 70OO
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Catawba County Environmental Health
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Parcel: 378110267296, 5268 HUDSON CHAPEL 1 in=300ft
RD CATAWBA, 28609
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Copyright 2021 Catawba County NC
12/02/2022