HomeMy WebLinkAboutWELL-03-2023-192144.tif .: t'.1T:Ut B.►('ul K t1 ('a.,'a Wili.1.d0-202;-192 I.1•I
Public Ilcalth Ocp,ulmcnt Sutdn Loaf CRESCENT LAND AND TIMBI
• h.mrtonmcniat health Ilnrsnnr l'INb 460715639431
PIIItos 1119 2i(io•,ernrncni Div..: \e,uom N(' :Xf I(PI- 107
Site Address: 4021 CHEVLOT HILLS RD, SHERRILLS FORD NC 28673
Berne on Permit: Ivi1GUEL 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
„�JyI certif.. that I am the'loner or authorised agent tooner's uuthoriiatiun required)representing the under,
il
the property described also.e.
7t; As the properly owner or authorized representali.e. I have received the above referenced
permits)as requested in the application t< r service RRPR-01-2023-43124. h) the tullouing method(s):
Recei.ed in Person
Facsimile Transmittal (Return thou with signature required)
,/ Electronic Image'transmittal.' E-mail (Return receipt required)
As the property owner or authoriied representali.e I have re%ie..ed and understand the specific conditions
(it the 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(I5A NCAC 2C .0100), shall apple to the issuance of this permit and
the construction of the wastewater s.stem and`or..ater suppl> well permitted.
Permit ksue Date: 03+2412023
Owner Authorized Representati.e Signature /
Date _ 3ja-_z . .0 Z
Documentation of Permit(s)Transmittal
(permit transmitted b) electronic or other means)
Permit transmitted by (mow qt p'r•.om.1cNrliue permit)
n n ._,Signature (it I)atc rime L.. )vt)3
Method: Fax 'Email IiS Mail `Other
Owner's request to send by the:those indicated method of transmittal in lieu of signature
We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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�� CATAWBA COI INTI' Case# W11.1,-03-2023-192144
!~ �� Environmental
2 Public Health Department Subdivision CRESCENT LAND AND TIMBI
„ `1 ironmental Health Division PIN# 460715639431
PO Box 3t 9,25 Government Drive.Newton,NC28(iS8 i o i'# 107
/8 2 w
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, R on Hwy 150, R Cheviot Hills, Property on Let w/lot directly across the street
WELL ABANDONMENT PERMIT
Well Type: Drilled
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/- flillic
03/24/2023
Authorized State.Agent Permit Issuance Date
3/24/2028
Permit Expiration Date
chpcinui 03i24/2023 11:14
i
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Parcel: 460715639431, 4021 CHEVLOT HILLS lin=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.
Cnnvrinht 71173 C:atawha Cniinty NC
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(_'tiMhrtunl t('6vcW1,\4`I 11llxrrl 7g,Piii,liC.�ii'ii brle .e f drt 1p11uu of itn•abandonment irrredure;
ikViNnoul 01AAAtttti t\\.4i tg RAuntl t Millet lrvplain motet'gl _f' 0Peg/ l
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d,Date t.ell(s)abandoned:_ �[..Y /62,f I
$44.Weil ktcation:
at,s2.6 21ti r
la•ih tsal,d\.n,e F.:11%4 the(if applicable) 8.('erilfleutlou:
r4 4 >J�, ZIL Rel 7. / L-1-13-.2.3
J !'andlki' � Signaiurc of i111 ied Well t'i4,111KW1 or WellI halo
(1-�R $or 7G d 7 (J+,6'a viz z t Ri signing this fi.rn, 1 hrvrin'rerri(i•that r!!(r) was Nor)ala+nduned u+
C,vn• t'anvl Waorti.anon NO.INN) I' r
utxr+ndanrr with 13:1 A'(':I("0_( ,I110t1 w•.t C.ft.Oft Wen Con.+trur•tiun Standards
ruin that a u-opt'y!thia rstrud hits hero prueidrd to the well owner.
5.b,Latitude and longitude hi degnervlutnuteslsreanda or decimal degrees:
to well fichi one la kte L.cunktnil 9.She diagram or udtllllonal well detallr,
W You may use the back of this page to pmvidc additional well sitr details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DET,t1LS OF WFLI(S)BEING 1tlAMUUNFEl) ,5UIIMI1TA1.INSTRUCTIONS
1+e.,4.+i:,,,a.vl+, .. .,.tn •rdil)a a,.oi,.1l.. Il..walry+'.o . ,i•.,I... ,.,MOW•w nU r I141r/r,Irllt
(MI'..r.I$.,,awe.IK,Atn 11. 1 aNR.AN.4 41.1.'....+R.uf.... 1..n,.r,4 n1
101.Fur AU Welly Submit this form within 30 days of completion of well
bit Mill IUIr abandonment to the following:
^� Oh Rion of Water Resources,Information Processing I.
but.Total aril depth: / ,5 v (R.) 1617 Mull Service Center,Raleigh,NC 27699.1617
IOb.For lokellat Wc111: hi addition to sending the form to the address in I Ou
6c.Borehole diameter: (9 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level belt%+ground surlier: .2. (ft.) Division of Water Resources,Underground Injection Control Program,
io3o Mall Service Center,Raleigh,NC 27699.1636
Or.Outer easing length(if knot+n): LI I (ff,) 111e.For M'ater Stmitit,@ Infection Wells: In addition to sending the form to the
�L addivas(ts)il6ovr,also submit one copy of this loan within ttl days of coin/Action
of %%ell abandonment 10 the county health depanment of the county ohere
6l.Inner easittg'lubing kaglh(If Anon n): (ft.) abandoned.
tug.Screen length(If known): (fl,)
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