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B CATAWBA COUNTY Case # EHPR-10-09-2420
Public Health Department Subdivision
Q . Environmental Health Division
PO Box 389, 100A Southwest Blvd, Newton NC SectionBl/Ph/Lot#
1$ 2 sra (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 PIN# 461820905357
j Applicant/Owner Duke Energy Carolinas LLC
Site Address: 3275 Harvel Road, Terrell, NC
Property Size: 2.829
Directions: H 150 E, LT Harvel RD, Property on LT
WELL ABANDONMENT PERMIT
WELL TYPE: DRILLED, BORED, DUG, ETC rII
I1 Is 0
S BY: PERMIT ISSUANCE DATE -
GN11 P65MflO)
R OR LEGAL REPRESENTATIVE DATE =
WELL ABANDONMENT INSPECTION
TOP Y OF CASING MATERIAL REMOVED (BORED WELLS YES FV~ NO ❑
WELL DISINFECTED: DATE p INITIALS rb~jN1
WELL FILLED WITH APPROVED MATERIAL
(BORED OR DUG WELL ONLY) I v DATE INITIALS
WELL GROUTED TO SURFACE (DRILLED WELLS ONLY DATE (o O INITIALS
WELL CAPPED WITH CONCRETE DATE INITIALS W\
! WELL ABANDONMENT REPORT RECEIVED DATE-11 III I0 INITIALS
PERSON ABANDONING WELL
OWNER DATE
CONTRACTOR R(w I r l Y vcn s DATE Iv
i
Wells shall be abandoned in accordance with all state and local regulations and rules. The Well Abandonment Report must be
sub 'tted to the ealth Depa ent within 30 days upon completion of a we .
AUTHO D STATE AGENT COMPLE ON ATE
i
C:1Documenu and Settingsljenglish\Local settings\Temporary imemet Files\Content.Outiook\P6CRMTUF\EHPRI0-09-2420 WELL
ABANDONMENT PERMIT.docx
TRACKING INFORMATION
Date Calls
11/02/09 1st Contact - Discussion Only EHPR-10-09-2420 and 2422 Left message
11/02/09 Site Ready to be Flagged
11/02/09 Site Flagged
11/02/09 Site Ready to be Evaluated
11/04/09 Site Evaluated
11/05/09 Approved for Issuance
Other
Date Comments/Field Notes
11/5/09 Spoke with Elena Massimini. Told her well abandonment permits would be issued and ready
for pickup today.
`II NOV-18-2009 WED 12:45 PM McCall Brothers FAX NO, 7043982605 P. 03
Ij
i
i i ~ YSSAA •
i a r WELL ABANDONMENT RECORD_
North Carolina Department of Environment and Natural Resoutoe5- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR: S. WELL PETAILS:
Diameter
fl. -
} a. Total Dgffl-ql~_.._
Wcil Contractor (individual) Name b. Water Level (Below Measuring Point): n
Meamnific point ls, 7. t!• above land surface.
well Contractor Company Nana
Sl'iZMET ADDRESS 6. CASING: Lettgih Diatnetcr
Ir$ 2 a. Casing Depth (if known): IL. In.
City or Towu Smtc . Zip Code b. Casing Relnovcd fl• in
Arcataodc -hanenumbcr 7. 1)IStNFEC170No~Ia~1 ]L,M_ttol.'~~
2, WELL INFORMATION., (Amount a 65% 75% calcium hypochloritc used)
Srrt? WELL ID # (if applicab(c) & STEALING MATERIAL.
STATE WELL PERMIT # (if applicabla}, ~'eaR ~cm~4 d
C Ct:ment a„^ 1b. Cement 1b.
COUNTY WELL PERMIT 0 (if upplicabic) Water Eel.
DWQ or OT]i1EIt HERMIT ff of applicable) entonil ,
WELL USE (Circle applicable use): Monitoring eldentl>t I3ertlonita
KunlelpaltPubltc indu5tr•[v1lCatnmerclal gr nral Type,. Slurry_ Pellets-
Itecovory Injecfion Ir•rlgatlon Wain ~1.
Other (list use)
Otkc>•
3.WELLL TI`O~N: Type,nalerial
COtJA1 N6! ub;& QUADRANGLE NAME
NEARESTTOWN: TnAmount
(StmetlRoad Names Number, CaMuniLy. Subdivision. Lot No.. Parcel, Zip Code). 9. EXPLAIN METHOD or r%MPLACEMENT OF MATfr1tL
TOKIGRAPHIC/LA $l?TfINd: ri ial rte! - "
Slope VaIlcy tat Ridgy Other
f (Circle app ate setting)
M ay be is daVMS
LATITUAEs b 1 minutes, seeouda. or in a
LONGITUDE 0 57. ~$a! deciawt rormat 10. WELL DIAGRAM: Draw a detailed sketch of the wall an the back of this W- to
Lat1[ttWt}[tgitlide s0ltree' GPS TOpograpitiC map form showing tout depth depth and diameter afscreens (ifany) romaiging
it, tha wetl, gravel interval, intervals of caning perforations, dad depths and
af be shown on a IfSGS mpo nW and
(Location of well int
atradwd (o thisform if pot using GPS) types orfin materials uaed.
4x..FACILITX-Taa natne of the btuiness whnv du' well is located. Complete 4a andOL ( r L
(Ifansidm xiol well, skip 4a: complato,4t A. well owner ioformation onV ) . 11. DATE WELLABANDONFM
1 ACiL1i Y ID #(if applicable) C. -
I DO }I kMj CEMTIFY THAT THIS WRLL WAS ABANDONED IN ACOOROANCE
NAME OF FACiI.rr W" 15A NCAC 2C. WELL CONSTRUCTION STANDARDS, A14DTHATA COPY OF
THIS RECOttD HAS SEEN rRflVIDSD TOnIS WELL.OWNEEL
STREET ADDRESS
luf- -Z fnw 2--
City or Town Stato Zip coda 51cty R C rtEV tvF1.1. CON tat atr7 oR PATS
Ab. CONTACT PERSON/RT.LL OWNER:
NAME F-L C Aj SIONATIlRE OF PRIVATE WELL OWNER ARA DOMNG THF. WELL DATE
aM pilvate weal owner must bean individual who & cbAadaW hWhcr n 1&fllal =0
STREET ACIaItESS ;K'3 ZU E• yL_~ E~Q in accordance with 15A NCAC zC -e t 13.)
11 N-c• 2 8G1~1
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