HomeMy WebLinkAboutWELL-03-2023-192096.TIF Y
AI CATAWBA COUNTY
.1. Public Health Department Subdivision
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Environmental Health Division PIN# 372119511871
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PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 2
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Site Address: 2500 STARTOWN RD, HICKORY NC 28658
Name on Permit: PIEDMONT COMPANIES INC.
Property Size: Acres 15.44
Directions: Startown Rd, right onto Valleyview Dr,property on the right
Owner/Authorized Representative Acknowledgement of Permit Receipt
I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the property described above.
As the property owner or authorized representative,I have received the above referenced
pertnit(s)as requested in the application for service EHPR-03-2023-43699, by the following method(s):
Received in Person
l Facsimile Transmittal (Return form with signature required)
J Electronic Image Transmittal/E-mail (Return receipt required)
SAs 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(15A 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: 03/23/2023
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature E Date/Time WI
Method: Fax 1 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 yoiPlease ttake a few momentts tto complette our custtomer service survey aft
http://www.surveymonkey.com/s/EHCusttomerService
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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 1 GW-30 is needed. Indicate TOTAL NUMBER of
4539-B wells abandoned:
7b.Approximate volume of water remainingwell(s): Unknown (gal.)
Well Contractor Certification NumberPP in (g )
Catawba Valley Engineering & Testing FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 12.5% sodium hypochlorite
2.Well Construction Permit#: EHPR-03-2023-43699
List all applicable well construction permits(i.e.(IIC,County.State,Variance,etc.)if known 1.0 liter
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) IBResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation NI Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge °Groundwater Remediation 2.5 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:
OGeothermal(Closed Loop) ❑Tracer Plumbing removed,disinfectant introduced,filled with grout to surface
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 3/30/2023
5s.Well location:
Piedmont Companies, Inc.
Facility/Owner Name Facility ID#(if applicable) K.Certification:
2500 Startown Road 04/11/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Catawba 372119511871
By signing this form, I 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/long is sufficient) 9.Site diagram or additional well details:
35.681716 N -81.272556 Nt 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)iifavailable. For multiple injection or non-water supply wells
ONLY with the same constructioniabandontnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Well-03-2023-192096 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b Total well depth: 165 (it.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: Unknown (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (1t.) 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
fit.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