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Home My WebLink AboutWELL-06-2023-199272.tif cNr vHA COUNTY Cuss It WELL-06.2023-199272 2 Public Health Deportment Subdivision CLEARVIEW ACRES PL 9-50 d --1 Environmental health Division PINY 372306493288 PO Box 389,25 Government Drive,Newton,NC 28658 I,t71"N 12 Site Address: 2408 28TH ST NE, HICKORY NC 28601 Name on Permit: BILLY BAKER property Size: Acres 0.36 Directions: Springs Rd NE,left onto 28th St NE,right to stay on 28th St NE,right onto 24th Ave NE.property on the left Owner/Authorized Representative Acknowledgement of Permit Receipt J —` I certify that I am the ov.ncr or authorized agent(o,+ncr's authorisation required)representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced i permit(s)as requested in the application for service EHI'R-O5-2023-44452.by the following method(s): i Received in Person Facsimile Transmittal(Return form with signature required) 4 Electronic Image'Transmittal/E-mail (Return receipt required) _ As 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(I5A NCAC I8A.1900), and/or Well Construction Standards(15A NCAC 2C .OI OO), shall apply to the issuance of this permit and the construction of the wastewater system and/or water supply well permitted. ::: e Date:06/30/2023 horized Representative Signature - �' Date CS M .b ' �,n , mot _ i I'� i I� Documentation of Permit(s)Transmittal Ai,J111 , i : (permit transmitted by electronic or other means) F i'{1 • (name a person sendingpermit) ;�'! i : s' Permit transmitted by—_•-_- _.. ___ . _ _ -. 1/ / ) ,'WA r ' r l; t ; i 1 �/ Date/Time Cjr 1..(-' } j Signature _ — --- Method' Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature l'=' - __ We wantt tto hear from yoi Please ttake a few momentts tto comptette our custtomer service survey att d iuT itiii ,��+, http://www.surueymenkey.com/s/EHCusttomer5ervice iiiiA ,;;I<tn a at 1t. i :r:.r, rl i5t t rw Ni b i N.. b A L,Q 6,4146obt ,$ he UI ilef jj , 7 i t j0�� t4Ii 1 l31"tl 1 �,� i„ 1� x� 1 t Wd 1,atl,f nit,;; 1)1)1 beR gi)(6 5at�kii, eget, ��i {iii3r �r,+t i {r 1 � ki t 'f}�A�I/tt 1 f 1 I t.. .� 'ir 1 lies(l�tt 1 ,}Ili , t el'! ;II 06r302023 t t:37 'S! tl': tito; �{{ ,it't :ITT iIpl�,�A, ��++ta IB�Cw a. t' ..;�ate "e .l .� 3 tl'Id aG:f, fl.. iisPili'!-' CATAWBA COUNTY Case# WELL-06-2023-199272 Public Health Department Subdivision CLEARVIEW ACRES PL 9-50 -1 Environmental Health Division PIN# 372306493288 PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 1 2 /8 sw Site Address: 2408 28TH ST NE, HICKORY NC 28601 Name on Permit: BILLY BAKER Property Size: Acres 0.36 Directions: Springs Rd NE, left onto 28th St NE, right to stay on 28th St NE, right onto 24th Ave NE, property on the left 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. 06/30/2023 Authorized State Agent Permit Issuance Date 6/30/2028 Permit Expiration Date chpennit 06/30/2023 11:37 -..-~ Catawba County Environmental Health g 1.) p R .....0., 5.ii----„-;„.,,Q0.623..,,, _........, -0---- RN 073:7 1 cp. ..ii dop • I A 0 ill/ . i:�wA� )� '( 1 ��.241 j —C1 _L1 I _~7.1 (172) co Lei °� Via ' t •240E1 air..-_ !Girt r1 ry 0— e >6? ,:l. ,L /L i �� R Drive i JOB •2821 74T"A ly e NE- 70Q 1865 e 2378 Parcel: 372306493288, 2408 28TH ST NE 1 in=40ft HICKORY, 28601 Thts map/report product was prepared from the Catawba County,r NC Goosned on patlal Information Services. Catawba County has made substantial efforts tto ensure he Independentt verificatio of n of anydata cond tained on thismepfrelport product by the user.The or data on ls Cou report. of Catawba.Its employees,oyees,agents, romotes doamdmends personnel,disclaim,and shall not bo held liable far any and ell damages,loss or liability,whether direct,Ind:rod or consequential which arises or may arise from this map/report product or the use thereof by anCopyright or t t Cwba County NC 06/06/2023 WELL ABANDONMENT RECORD For Internal llscONI.Y I.Well Contractor Information: WELL ABANDONMENT DETAILS 3 4,Y 4'r•t:.�� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Conuactor N (or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of 2-1.11 — (� wells abandoned: NC Well Contractor Certification Number 7h.Approximate volume of water remaining in well(s): I LGf) (gal.) itv-t Sc r ryALL,_.)�14f '11;i el ej1 v,sliN S FOR WATER SUPPLY WELLS ONLY: Company Navin J 9 7c.Type of dLsinfcctant used: .S Vs .‘:')av I.-- f�11 (� 2.Well Construction Permit N "t): "'ZL ut.3'' ,j jG j 1, List all applicable melt construction permits(r a UIC County,State.Variance,etc.)ifknorn ;. 7d,Amount of disinfectant used: ) Lin° Z 3.Well Ore(check well use): t Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 71.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 ❑Drill Cuttings ❑lmgation 0 Specialty Grout 0 Gravel Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g) °Monitoring °Recovery Injection Well: 71.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediatiun A.•, c1 - , ❑Aquifer Storage and Recovery ❑Salinity Barrier t' l f,r y ❑Aquifer Test OStormwatcr Drainage Sli i k? 4 C.,:'1u . C..i ❑Experimental Technology °Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ( , i. ` °Geothermal(Heating/Cooling Return) °Other(explain under 78) �,.,\,, . .liZ.,.,Ari1l ~ (AI �st� 1��. 'L_ ,C�W;'NVsL �-�� A Arlo-').�`e 1'n v'V'�,lr� V.YA CAs:,vi. 1:ZF4 D.'t 4.Date well(s)abandoned: Sa.Well location: + Facility/Ouv Name Facility IDb(if applicable) 8.Certification: �'�'1 ��'`'r \�'T t�I�'� �i'�J V t(iv�CO'y. Physical Address,City,and Zip Signature of died Well Contractor or Well Owner Date G0W C\ ,1 siL (ii4L, ap) By signing this faun, I hereby certifi'that the well(s)was(mere)abandoned in County Parcel Identification Nu.(PIN) occoixlance with 1 SA NC.IC 02C.0100 or 2('.0200 Well('uuslrnclion Standards and that a copy of this record has been provided to the well owner. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one hI/long is sufficient) 9.Site diagram or additional well details: C.71 JC 6i T t J Li / `N �q f ji I /4 W 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 constnrction record(s)Ifaroilable.For multiple infection or non-srruer supple melts ONLY rs1Ur the same construction/abandonment.you can submit one farm. ` 10a. For All Wells: Submit this form within 30 days of completion of well E1 6a.Well IDN: 41 abandonment to the following: +..„ Division of Water Resources,Information Processing Unit, 6h.Total well depth: 1 (-5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 A ` �(� lob.For Injection Wells: In addition to sending the form to the address in IUa 6c.Borehole diameter: ,\y F) (In.) above, also submit one copy of this funs within 30 days of completion of well abandonment to the following: Division of Water Resources,Underground Injection Control Program,Ed.Water level below ground surface: l�' (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): IL' "' (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to the address(es)above,also submit one copy of this form within 30 days of completion r� of well abandonment to the county health department of the county where 6f.Inner casing/tubing length(If known): N i"i (ft) abandoned. 6g.Screen length(If known): ill (ft.) I ire Ow-;0 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2--22-2016