HomeMy WebLinkAboutWELL-08-2023-201655.TIF c CATAWB:A COI'Nils ...
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Awl ironnuntal health I)Ivoi"n 1'INIt 461601364771
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Site Address: 8438 NOLLEY LN,SHERRILLS FORD NC 28673
Name on Permit: 'GRAINDA BUILDERS INC
Property Size: Acres 1.16
Directions: 1-77 W onto Hwy 150.Left on Slanting Bridge,Left on Drena Drive. Right on Giles Ave.Turns into Moore St
then Nolley
Owner/Authorized Representative Acknowledgement of Permit Receipt
....... I certiI\ that I am the owner or anthorired agent towncr's atlthuriratinn required)representing the owner of
the properly described shove.
. As the property owner or authorized representative. I have received the above referenced
permit(s)as requested in the application for service RBPR-03-2023-43903.by the following mcthud(s):
Received in Person
Facsimile Transmittal(Return lbrn)with signature required)
IIileciionic Image Transmittal!li-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(15A NCAC 18A.1900),
and/or Well Construction Standards(I SA NCAC 2C.0100), shall apply to the issuance of this permit and
the construction of the wastewater system and/or water supply well permitted.
it
- Permit Issue Date:08Q/2023 ,, '
•
Owner/Aut)orized Representative Signature ) 6 rearlda., @wildwr,
— Date ._. (� .I 5! Z.
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (Milne o/person SOltd(i))C pt'rmir)
Signature 4c Date/'Time %hi/V
Method: Fax .1 Email US Mail Other
1
Owner's request to send by the above indicated method of transmittal in lieu of signature
We wantt tto hear from yotPlease ttake a few momentts tto complette our custtomer service survey att
http://www.surveymonkey.com/s/EHCusttomerService
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• CATAWBA COUNTY Case# WELL-08-2023-201655
Public Health Department Subdivision CRESCENT LAND AND TIMBII
.,�a Environmental Health Division PIN# 461601364771
�V PO Box 389,25 Government Drive,Newton,NC 28658 LOT# 60
Ig42 w
Site Address: 8438 NOLLEY LN, SHERRILLS FORD NC 28673
Name on Permit: *GRAINDA BUILDERS INC
Property Size: Acres 1.16
Directions: I-77 W onto Hwy 150, Left on Slanting Bridge, Left on Drena Drive, Right on Giles Ave,Turns into Moore St
then Nolley
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 I lealth within
30 days upon completion of a well abandonment.
Well contractor must schedule well abandonment inspection with Catawba County Environmental Health.
08/03/2023
Authorized State Agent Permit Issuance Date
8/3/2028
Permit Expiration Date
ehpennit 08/11/2023 15:58
W ' ' ,1I3ANDONi1'11?N"I' RECORD foc,nrrtru,t'.rONLY
1,dellContractorInformation:(� I ��E „1g1SDnN� T D' '
I�{r �. h i C 4 l ` 1a.For l;mproba{DJ''F or Clowd�Loop Geothermal Wells basing the same
g+—'— - rt i 4Y L C,��'.}0 rs nrcdcd Indicate TC)TAL NUMCIRR of
} sill construcuun iepth,on '
w ell Contractor Nano(ot will au net Prrs,vseily ahandnnmg u it on hrtilur pmf,rn)i __..___._ - —
well abandoned,
NC will Contractor Certification Number 7b.Approtimatr volume of water rcusaining In well(s): 0 (gal.)
.� �� �, r [ FOR WAl LR SU?PLl'11'FLLS ONLI':
Conan'.':mot Q Y i A t
7r 7spr of disinfectant used:_
2.Will Construction Permit o:PS�"
— z ' lLlf..f - g Du✓t 6�S
lrrr�!appircahlr.d:cnnstnKrren ptrmrn n r i;l(:Cmmrv.Starr,lonance.eft 1,11a•rnn 7d.Amount of disinfectant used:�.—
3.1%e11 use(chick w ell use): —
Water Supply Well: ---- 7e.Sealing materials used(check all that apply):
ntonilc Chips or Pellets
( Agnculmra: 0Municrpatfubllc C Neat C ement(trout
0 Dry Clay
O(icothamal(MeaungtCoohng Supply) sidential Water Supply(single) ❑baud Cement Grout 0 Doll Cuttings
OlnduslnallCommercial OResidential Water Supply(shared) f,?''(Oncrcte Grout
[':Imeaoon 0 Gravel
❑Specialty Grout
Non-Water Supply Well: 0 Hen,onite Slum} 0 Other(explain under 7g)
Mcmnulusg ORecovety
Injection Well: ' 7f,Far each material selected above provide amountl of materials used:
oAgmfer Recharge ❑Groundwater Remediatron `' —
OAquiler Storage and Recovery OSalinity Harrier 0Stormsvater Drainage
❑Aqudrr Test _ I s(-{/ ti
°Experimental Technology °Subsidence Control 7g.Provide a brief des 'ption of the antes procedurea/
❑Geothermal(Closed loop) OTracer h� �- / �/
OGcothcrmal(Heatin 'Coolie Return) ❑Other(explains under il;t
4.Date well(s)abandoned:,1 i 1 I.23
Sec.Well lucatiea: / l
: et ls Q u . I dr r A — —
Facility IDa Of sfphcabin S.Certification:
Pacihry�Ownct Name }�
Physical,ddrers.C op,ant Zip sigutur i Lcni ie N'rll enui:ror o tfrn Date
PAlci..J 44 41,12 1 bo (34217?t Br signing this form, I berth, c fy that the isctlisJ was rnerc)abandoned in
r"...ants PM CO:dcantl.ation NO t,'IN t accordance with 154 NC.4C O. .O100 or?C.O200 Well Construction Standards
anJ that a copy of this record has hcen presided to the nell owner
Sb,Latitude and longitude In degrentminuttl seconds or decimal degrees:
i,,r wet:ficht unc Wieng ii surficicnl l 9.Site diagram or additional weft details:
You may use the back of this page to provide additional well site details or well
N W abandonment derails. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
..leach cellcamtracianrecordistrforadahke Fur multiple Injection ornos.natermpplvn:Hs
On f»,rh rhr,air crntrwcumr'aM radon+trot mu con mhmtt one linen
10a. Fur All wells: Submit this form within 30 days of completion of well
abandonment to the following
ba.Well IN: _
Disislon of Water Resources,Information Processing Veit,
1617 Mail Service Center,Raleigh,NC:7699-1617
tib.Total well depth: //O �IfL)
,t)b.For lnlecdon wells: In addition to sending the torn to the address en 10a
he.Borehole diameter:_ ...5- .._ (la.l above also suborn Doc copy of this form within i0 das,of completion of wed
/� abandonment to the folivv.mb.
bit.Water level below ground surface: -3 _—(ft.) Division of Water Resources,Underground Infection Control Program.
1636 Mail Service Center.Raleigh,NC:7b94.1 his
(re.Outer casing length(if lenorrn): ((I,) Ilk.For Water Supply 4....1.6 erttrinflIV 1n addition ur sending the unto in'Ore.
add(east es(above,also Subuut use cops of this form within'lb days of c nnptrtron
of welt abandonment to die county health deparlsnr•ra of the county where
]t}Jnd�Nrfd.
6f Inner casing,tuhme length DI known):__ __(ft.)
6g.%men length(if known): Ski
fry Lw'Jh
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