HomeMy WebLinkAboutWELL-02-2023-190199.TIF 4;wie CATAWBA COtiNI'Y eases K'[••.Lt-02-202 190199
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I.•. , tF Environmental Health Ih�tsion PIN* 371412960319
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Site Address: 3621 16TH ST NE HICKORY NC 2:6u 1
Name on Permit: BCDG-BEAR PARK LLC
Name on Permit: CATAWBA VALLEY ENGINEERING
Property Size: Acres 11.19
Directions: 16th St NE past 36th Are Dr NE ('7.'15! +ir't rr.;•^!'anct•'r,left
Owner/Authorized Representati►eAcknowledgement of Permit Receipt
NA. __I ccrtiij•that I am the owner or authorized agent lt'«ner's authorization required)representing the owner of
the property described above.
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As the property owner or authorized repre:.ent.ttit e, I have received the above referenced
permit(s)as requested in the application for servic.: EIIPR-02-2023-43410,by the following tnethod(s):
_ Received in Person
_ Facsimile Transmittal (Return form v.ith ;i:.rtatatre required))
NI Electronic Image Transmittal I.-mai! (,Belem feet:' ••: required)
si YY__ As the property owner Or,tuthori•r.:d t epee•en di : ! hti.e reviewed and understand the specific conditions
of the permit issued, and further unalc'i :land tl :.t :tit ;i1,;the•ahle regulatory requirements specified under the
North Carolina Lams and Itul-s Ito- New:ttt, •rcatment and Disposal Systems(15A NCAC 184.1900),
and/or Well Construction Standards(15.4 NC-4( 2t .I)1 OM. •hall.apply to the issuance of this permit and
the construction of the wastewater ,i.ni.ir.l i r%..,t • i"":-'. )t• : peril lilted.
Permit issue Dale:02127,2023
OwncriAuthorized Representative Signature
Date 3�—/-2 5 cc��--
Documentation of Prrinit(s)'Transmittal
(permit transmitted b) electronic or other means)
Permit transmitted lay worm,ojperswt sending permit)
Signature • () L., Date/Time 3h i)3
Method: Fan 'I 1•an:ril (IS flail Other
Owner's request fo wild 'ry the al•m t• inilicatctI method of transmittal in lieu of signature
We wantt tto hear front yc.i.Plca:e gale-a c rnernrr,tl:i no complette our custtomer service survey att
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Cody Dobbins 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
4539-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 563 (gal.)
Catawba Valley Engineering &Testing FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: 12.5% sodium hypochlorite
2.Well Construction Permit#: EHPR-02-2023-43410
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)ifknown 1.5 liters
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) •Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation I Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry Li Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 23 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Plumbing removed, excavated top 4' plus 1' buffer around well,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 i)
introduced disinfectant,filled with grout,created plug at ground surface.
4.Date well(s)abandoned: 3/30/2023
Sa.Well location:
BCDG-Bear Park, LLC
Facility/Owner Name Facility 1D#(if applicable) S.Certification:
3621 16th Street NE, Hickory, NC 28601 < �_r'- %r 04/11/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 371412960319
By signing this form. 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat,ieng is su:iieient 1 9.Site diagram or additional well details:
35.778775 -81.295727 , 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. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: WELL-02-2023-190199 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b Total well depth: 44 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 48 (in.)
abandonment to the following:
6d.Water level below ground surface: 38 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016