HomeMy WebLinkAboutWCOC-01-2023-187010.TIF `. CATAWBA COUNTY Case# WCOC-01-2023-187010
Public Health Department Subdivision
Z Environmental Health Division PuN# 371318309170
PO Box 389,25 Government Drive,Newton,NC 28658 LOT#
/8 s.
Site Address: 144 15TH ST SE,HICKORY NC 28602
Name on Permit BOBBY WALKER
Property Size: Acres: 0.41
Directions: McDonald Pkwy SE,left onto Tate Blvd SE,right onto 15th SE SE
WELL ABANDONMENT CERTIFICATE OF COMPLETION
Permit Number: WELL-12-2022-185975
DATE COMPLETED INSPECTION TYPE STATUS INSPECTOR
12/05/2022 EH Well Abandonment Observed Approved Dean Evans
12/05/2022 EH Well Abandonment Report Received Approved Dean Evans
12/05/2022 EH Well Capped with Concrete Approved Dean Evans
12/05/2022 EH Well Disinfected Approved Dean Evans
12/05/2022 EH Well filled with approved material Approved Dean Evans
Owner-BOBBY WALKER 12/5/2022
Abandoned By Date Observed
/1/71............. Deq4 rogri.S.
12/05/2022
Authorized State Agent Issuance Date
eltwellc.w 01/05/2023 11:32 Page I of I
Catawba County Environmental Health
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Parcel: 371318309170, 144 15TH ST SE 1 in=40ft
HICKORY,28602
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Copyright 2021 Catawba County NC
01/04/2023
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�� � 7,_%' North WELL ABANDONMENT RECO
Caroling Department of Egviron>»ent and N
WELL CONTRACTOR NH aRasl Resoterses Division of Water Quality
Lvdr LcoNTRAcrok: CERTIFICATION
R WELLDET
Well Contractor(Individual)Nam' ' DETAILS:
L Total Depde Z�
b.Waster Level(Below R O is
Well Contradoe �e+�
•
STREET ADD mpanysane Measuncg point h Measuring_ R above land ce ADDRESS surface
6• CASING:
City or Town State 4n DiameterZip Code a-Casing Deem(dawn):
�' b.Casing Removed: �� —�is
Area code-Phone number I _ �
Z L LN'BORMATION; 7• DISINFEC ION. C+a ro C f
SITS WELL ID A(if applicable (Amon t of 65S475%calcium
L SEALING MATERIAL:
used) 1
STATE WELL PERMIT 4(if applicable
Marsala!,
COUNTY WELL PERMIT t(if applicable)
Cement 'lb.
. DW OTHER PE Wars Cement
Q°r RMiTif(ifapplicabk� • gal, Weirs. �-
•
WELL USE(Circle applicablerise) MonitoringBentonite
ential
MasieipaypabGe IadaetriauCommercial Agricultural
Recovery IajectIoa Irrigation • Bastonile lb.
Other(I use) - Type:Slurry,.Pellets_
Cal,
3-WELL LOCATION
O�beL
/� / 41...._______
COUNTY 4 I7K Qv BANGLE NAME >)pereareral ICQ/I Li
NEAREST TOWN: - Co r-
. Amount
(Strom/Road Name,Number, Subdivision, .Camnumir7, Lot Na.pout,Zy Code) 9. EXP IN METII D OF EMPLACEMENT OF MATERIAL •
TOPOGRAPHIC/LAND SETTING: q
Slope Valley Flat Ridge Other � e4✓� GtA r/
(Circle appropriate teeing)
LATITUDE — Mry be a drera�
LONGITUDE_ — ______
min"la'rondo.a
oe. io a
_ decl forum
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
aiiting
Latitude/longitude source GPS Topographic ma
•
(1•ocation oboe must be Owen on a USGS ropo map and P farm showing total depth,depth and diameter of screens(if any)rtm
arrathed to drat form(fnor uring GPS) the gravelinterval,intervals of casing perforations,and depths and
AIL FACILITY-The aao r°�� types of fill materials wet
burros where the well is looted.Co raplese
(if s residential well,rip lr,eompicle 41%wJl owns information only.) a andsb. /
FACILITY ID Y(if applicable) 12
11. DATE W N
WELL ABANDONED /
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED-
IN ACCORDANCE
NAME OP FACILITY
STREET ADDRESS WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
City or Town gram Zip Code
P SIGNATURE OF CERLtPIED W ELL CONTRACTOR Its.CONTACTPl1rSON/WELLO�R /f DATi
► �N I.owN. :r 1-)'1( ray' ..2— 1 i
r.- SICNATURz OF PRIVATE WILL OWNER ABANDONING 2T1 9Vg�/��STREET ADDRESS
/L)}n S S_ (new Pnvaer wi ewar ewt M as edirtidui who LL BATE
��a le amcreme'w hI SA NCAC 2C.0113.) t1�a1b:retiree tauL�v rea,dadal wets
i-Jo r N C- 1 ,» w d.i,d,.
Or Tow, Stu Zip Cade rlunffED NAME OF PERSON ABANDONING THE WELL —
or
Amu code.Phone nlarber
Torres
Sabena•cap to die owner lad the otiglul to the Divides of Weser Quality wirhi.30 days.
Apo Warns do
e htaaag'ta'at 1617 Mali Sanrke Caster-Rakich,NC 27699.1617, Moe Na(919)731-7015 en 56g- .5)06
Rev,5/06