HomeMy WebLinkAboutWELL-07-2023-200437.TIF �`tla1y� CATAWBA COUNTY -
/t 1?O Public Health Department
Subdivision
10 , /� Environmental Health Division
PING 461703407819
��.-40 PO Box 389,25 Government Drive,Newton,NC 28658 LOTS
i
Site Address: 8477 BABE DR, TERRELL NC 28682
Name on Permit: HUNTER LUNSFORD
Property Size: Acres 1.86
Directions: Hwy 150 onto Kiser Island Rd, go approximately one mile then turn right onto Babe Dr, lot is on the left
Owner/Authorized Representative Acknowledgement of Permit Receipt
I ertify that I am the owner or authorized agent(owner's authorization required)representing the owner of
the roperty described above.
! se
he property owner or authorized representative, I have received the above referenced
p as requested in the application for service EHPR-06-2023-44715,by the following method(s):
Received in Person
— Facsimile Transmittal(Return form with signature required)
Electronic Image Transmittal/E-mail (Return receipt required)
A s e property owner or authorized representative I have reviewed and understand the specific conditions
of M rmit 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:07/18/2023
Owner/Authorized Representative Signature
L Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
C)4ESignature Date/Time V)c3i .)j
Method: Fax 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 yoo.Please ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerservice
igce cafti. 65301),1) 6'04
ehpcmc 07/19/2023 13'44
WELL ABANDONMENT RECO I° ° - _�
'. Uac ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
510C 6c/-1 7a.For Geoprobe(DPT or Closed-Loop Geothermal Wells having the same
Well Connector Name(or well owner personally abandoning well on hisiber property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
L / ?�' C- wells abandoned:
_T
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (S+il•)
(r rtC 1../Q II cote,. FOR WATER SUPPLY WELLS ONLY:
1__
Company Name / 7c.Type of disinfectant used: t/'1 kV if f S"Q
2.Well Construction Permit it: �Li �f
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)If known 7d.Amount of disinfectant used: (Z' 9„v it f W
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
°Agricultural °❑�MM�unicipal/Public El Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Nicesidential Water Supply(single) ❑,Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) /Concrete Grout 0 Drill Cuttings
°Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f,For each materis)1 selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation j y p�)
°Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
Re"dt e tile ich.•0, -Q(ate y
CGr�tltermal(Heating/Cooling Return) ❑Other(explain under 7g) ��C/ le r ,� � �/� r�d��
4.Date well(s)abandoned: 514/X 3
Sa.Well location: 1
(uv„+tr)Let L.Vonfo/Q 8.Corti• 'tio
IacilityfOwnes Name Facility 1Dt4(if applicable)
. 4 7 - b • I( 0( Ql( Asi,.4,i �...m``' ).
Physical Address,City,and Zp l Cy Signature of Certified Well Contractor or Well Owner Dat
Cc. f t.c c LA 7 ''3 Q7 t/ ci By signing this form, 1 hereby certify that the well(s)was(were)abandoned to
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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:(if well field,one laUbng is sufficient)
1 - 1 You may use the back of this page to provide additional well site details oe well
S$ 7 N v W abandonment details. You may also attach additional pages if necessary.
CONSTRUC IONTL'AILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)IIf 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
abandonment to the following:
68.Well IDk:
Division of Water Resources,information processing Unit,
3 (ft) 1617 Mall Service Center,Raleigh,NC 27699-1617
6b,Total well depth:
IOb.fur Infection Welly In addition to sending the loran to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: I '�' (in.) abandonment to the following:
Division of 1636 Water Ieserviee,Unerground Conter,Raleigh,NC t27n699 1636Control
Program,
6d.Water level below ground surface; I 0 (ft.)
be.Outer casing length(If known): 444
10c.for Water Sum&lit the form to the
t Injection Welly In addition to sending
( ) address(ea)above,also subunit one copy of this form within 30 days of completionwhen
of well abandonment to the county health department of the county
6f.Inner rasing/tubing length(If known): Al '4- (tt.)
4.screen length(If knuwa); ! /A __lit.)
r'.rsn C)W.MY I.i,,..cl.(' s.li,u,tisp.+smnnt or liortrontrtentai()lathy•I)lviek,n or Water 14cww!wa Ren'ucJ 2•Z:-2016