HomeMy WebLinkAboutWELL-03-2023-192146.TIF i.: ('.V lAwn.t col-\i I, (.i'= Wh..I.I.-03.202 3.1921•1fi
Public Health Department `ulxln Ishii CRESCENT LAND AND TIMBI
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) I'm ii r,mental health t)Ruu'n 1'IN:1 460715639431
Pt)I3m 3149.25(imernment I)riw.Notion NC 28h;It I t I I d 107
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Site Address: 4021 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673
Nome on Permit: iviiGUEL JUNCO TRUSTEE
Property Size: Acres 0 9
Directions: Sherrills Ford Rd. R on Hwy 150. R Cheviot Hills. Property on Let wllot directly across the street
Owner/Authorized Representative Acknowledgement of Permit Receipt
V__ /I ccrtil) that I am the u++ncr or:wthuriicd agent(o++ncr•s authurirdifIn required)rcprescniing the boner o
• the Proper[) described abo e.
y,j + As the property owner or authorized represeniatiwe. I ha%e recci+ed the above referenced
permit(s)as requested in the application for service RftPR-01-2023-43123. by the follow ing nicihod(s):
Received in Person
Facsimile Transmittal (Return form with signature required)
.1 Electronic Image Transmittal' E-mail (Return receipt required)
Nt As the property owner or authorized representati+c I base re%ies+ed and understand the specific conditions
of he permit issued, and further understand that all applicable regulator) requirements specified under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC I8A.1900),
and/or Well Construction Standards(15A NCAC 2C' .0I00), shall apply to the issuance of this permit and
the construction of the ++st.3r+vater system and or+cater supply +yell permitted.
I l.a liii l sii. Date: v 12:% 023 LVLJ O++net Authuritcd Representative Sign;uu __ _ ���
L
Date 31 1-.il.t.0
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by . luume of person sending pi'rmil)
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Si 'nature L./
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__ ___. Date 1'irne
Method: Fax J Finail US Mail Other
Owner's request to send 113, the Jaime indicated method of transmittal in lieu of signature
We wantt tto hear from ytuPlease ttake a few momentts tto complette our custtomer service survey aft
http://www.surveymonkey.com/s/EHCusttomerservice
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Ire CATAWBA COUNTY Case# WELL-03-2023-192146
F., .t.II ,y Public Health Department Subdivision CRESCENT LAND AND TIMB1
'" Environmental Health Division PIN# 460715639431
PO Box 389.25 Government Drive,Newton,NC 28658 LOT# 107
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Site Address: 4021 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673
Name on Permit: MIGUEL JUNCO TRUSTEE
Property Size: Acres 0.9
Directions: Sherrills Ford Rd, Ron Hwy 150, R Cheviot Hills, Property on Let w/lot directly across the street
WELL ABANDONMENT PERMIT
Well Type: 2 inch punched
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.
41/— filli/
03/24/2023
Authorized State agent Permit Issuance Date
3/24/2028
Penmit Expiration Date
ehpennit 03:224'2(123 IIt13
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Parcel: 460715639431, 4021 CHEVLOT HILLS 1in=50ft
RD SHERRILLS FORD, 28673
This map/report product was prepared from the Catawba County, NC Geospatial Information Services, Catawba County has made substantial efforts
to ensure the accuracy of location and labeling information contained on this map or data on this report. Catawba County promotes and recommends
the independent verification of any data contained on this map/report product by the user.The County of Catawba, its employees,agents,and
personnel,disclaim,and shall not be held liable for any and all damages,loss or liability,whether direct, indirect or consequential which arises or may
arise from this map/report product or the use thereof by any person or entity.
(:nnvrinht 7f77:C:atawha C:ni inty NC:
,1'ELI. ABANDONMENT I\ECO12I) byIrrctn+l1.-•((t\1l
I.Well Contractor information: WELL X111\1)O\\(ENT DUE 11LS
Alfred Kiesling Jr 7a.For G(n+prnhe DP nr Closed-Loop Geothermal 11 ells having the same
q tN Contras"\mmt lot xtll rw:rr prntvul!+41\1talenrng wart rat his Err pmpt•rrsl
well Cr onit.nrn devh.,only I GW-::0)is needed Indicate TOT:\f.NUMBER of
3266-A wells ab,tnJotL'd
NC\\cif Contrwt,u Cent-Kitson\a:nhr 7b.:Ipprrsintatc solunic of stater remaining in well(+): (gal-)
B & K Well Drilling Inc FOR WAFER SUPPLY WEI LS ONLY:
Company`came Chlorine
7r,'Tye of disinfectant used:
2.Well Construction Permit q:.Lrd.\32744_3 -1 1 01.14 G_
LLu art appinaNr wit tonstrw-ion jvrrxal ji a 11C.Ctwnrv,&ore,1 arum a di.)it knows C�.r6� C•7,,.
7d.Amount of disinfectant used: /J
3.Well use(check+sell use):
Water Suppl)Nell: 70.Seaiing materials used(cheek all that appi)i:
❑Agricultural E\tunicipal Public .i.i-'tiat(cement(irvui —ttooite(-hips or Pellets
❑Garihcrmal(lieatrng Cooling Supply) SRc,idcntial Water Supply(single) ❑Sand Cement Gann 0 Dry Clay
❑Industrial Commercial DRcsidenual Water Supply(shared) 0 Concrete Grout U Drill Cuttings
Olmgation C Specialty Grout U Gru\el
Von-\Water Supply Well: E Bentonite Slum 0 Other(explain under 7g1
\lonitonng CRe-ioscry
Injection Well: 7f.For each material selected abuse.prosidc amount of materials used: hit
❑Aquifer Recharge ❑(iroundwata Repudiation - 0 j (2)- O, S h11Ie
:Aquifer Storage and Recovery :Salinity Barrier �� ��/ �� "'
:Aquifer Test ❑Stonnwater Drainage ( ea-.c
❑Experimental Technology ❑Subsidence Control
❑Gnuhcnnal(Closed Loo 7g.Pros ide u brief description of the abandonment procedure:
p) ❑Tracer /
❑Gctnhennal(licating'Csxsling Return) COther)explain under 7g) it 0Pate' 3t )4r,i/.
J.Date well(s)abandoned: 7[ i!A 3
Sa.\Well location:
A1 µ,. l Jtlr.e.duaf=I
Facility ChNncrNamc Facditc11)stiapplicable) 8.Certificaton:
L/bac aktrL N.16 pc -1 -
PPhhlsicaall Address,City,and Zip /�/jry Sieiuturc, . 'rnli yl\(' ,ni :tor or (;I! ctn t.'
(lGi•L.1 M.)Dsr `11, ` i 176 t''(t3 l Br signing,,is li,rni, I hrrthr cell I ,r!hi it l(•)ittt+ (nits•)2\1/11101M1 in
County Pared ldennicattott Ni 1Pl\) accordance mirth 15.-I Nti-IC 02C 3 ' or.C 31.u1)Will Construction Standards
and Obit.t e.Ty ul this retool has been provided to the well owner.
5b.Latitude and longitude in degreeslminutrsiseconds or decimal degrees:
(dwell field,one tat long is sufficient) ..Site diagram or additional well details:
You may use the hicl,of this page to prom ide additional well site details of well
N 11 abandonment details. You may also attach additional pagex if necessity.
CONSTRUCTION DETA11 S OF WEl.l.lSI OF.ING,sit VSDONF.0 SUB\lITTAi.INSTRUCTION,:
Itrarh well rutornnn<tnrrroi-tfh)itawtluhle. fib,tJlIl/iI('i(tOil.,Ott??I,'non-nowt..ulyrltuellt
UNL I'wish she S.M.'.nn i,,c iio,vahanJnnrrrror sou run.uhmir one pi to
10a. For All Wells: Submit this firma within 30 days of s:omplction of well
6a.Well IUti: ah,utdonnu•nt to the folks;mg:
Disision of Water Resources.Information Processing)'nit,
6b,Total well depth: 56) tits) 1617 Mail Sers ice('enter,Raleigh,NC 27699-1617
IOh, For Infection Wells; In addition to sending the hmrt to the addr .s in I0a
6c.Borehole diameter: Om) •+husk. ,ils'sublii1i rrie copy of this Corm svt1iitr 30 Jay of etsng+irtren of well
ahandonmenl to the following,
0 Di;isiun of Water Rewuree.,Underground Infection Control Program,
6d.Water level below ground surface: ltt.) 1h3(i Mail Sersice('enter,Raleigh,NE'27699-
106
6e.Outer vista length d{+wawa lit.) Ille,For Water Supply. lilies:film Wells: In addition to sending the ti+tat to the
& ( ) ;tddresaest, esse,also submit one ceps of this fisnn arthni 30 das s of ermplctiirtt
of well ahandianuent to llle cruet) health 0%1\uxntcnt of the county where
6f.Inner casing/tubing length(if known): (ft.) ahandoited.
6g.Screen length(if known): (ft.)
Form GW.30 \only Carolina Iiepanrnnt of Fn+m'nnwmal t)u.ilii(•Iht+.i.m of(('aver Roourer. ticst.cJ 2.:2-201b