HomeMy WebLinkAboutWELL-07-2023-200439.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
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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
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ehpcmc 07/19/2023 13'44
1
WELL ABANDONMENT RECO ' 1
«,rti -r 1 Usc ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
),444G (314tt fit)y 1144 7a.For Geoprobe)DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hislber property) well construction/do pth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
'to SO— wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
f"i ICk tutu �ell 5Q/\/, FOR WATER SUPPLY WELLS ONLY:
Company Name J 7e.Type of disinfectant used: C 1�r K•
2.Well Construction Permit#: oft.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: I 5�11�rp
07
3.Well use(check well use): t!
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtmicipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
:Geothermal(1-leating/Cooling Supply) fsiit'esidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial OResidential Water Supply(shared) li/ oncrete Grout 0 Drill Cuttings
❑hrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Shiny 0 Other(explain under 7g)
EMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation `,LI
❑Aquifer Storage and Recovery ❑Salinity Barrier r
❑Aquifer Iest ❑Stormwater Drainage
GExpainomtal Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
EGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) C.✓t co.c f.,s I.e((0 40 $ eq CI e
I 4 3 •'Fi(t et"d -Co r.ai p o.d l ro,p
4.Date well(s)abandoned: Ct.* 117
ti
l5a.Well location:
lam) L ls)n5cOtd0
FacilitytOwnerName Facility DU(if applicable) 8.Certifica•
iq-71 0,- efie ( RC 2$f. it y a
hyaital Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
(1-1-C xlin 7030161
signing this form, 1 herebycerti that the well(s)was
By gn g j fy (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.Ladtude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient)
9.Site diagram or additional well details:
S.S 7 N 60.9 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 construction record(s)!fm'ailable.For multiple Injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
61.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6h.Total well depth: I 0,r 0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.Fur lnlcvtiun Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: b (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: 6 (h,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Oster suing length(if known): /41 A OW IOe.Or Water Sujpiv&Jjectlun%Fells: 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
iL law eadag/lublag length(if known): N/A (rye) abandoned.
lei.Sasso kola Of known): 4/r4 (ft.)
Potm t3W30 Noah cam**I Rmtsod 2-22.2016
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le . )apattrosnt of lit►NronmenW quality•Division of Winn Resources