HomeMy WebLinkAboutWELL-11-10-12466.TIF 02/22/2011 17106 19297294410 CANON +71163 P 002
Ftli-• 1 -d(J11 1 ; 4 l..H I HWbN LUUN I Y UUV I 1 OGO •40..1 WC. - I 1
4 ,:,. N 4..A 1ftreDA 1 .0 1 .lUh1 a 8 ('.seta EHPR-1 0-1 0-7834
r Public Health DcparuncM
Environmental Health Division- Plan Review Subdivision
PO Box 399, 100•A Southwest Blvd, Newton NC 23658 Loth Al
ttt*V■• PIN# 371416931965
Applicant/Owner JUDY SHERRILL, 1721 NE 31ST AV DR, HICKORY NC 28601-
Site Address: 1721 31ST AV DR NE, Hickory, NC
Property Size: SF 1.309 ACRES
Directions: SANDY RIDGE RD/ BESIDE LAWSON CREEK SUB / DEAD END RD/
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� 1 Wtr, -L ABAND9NMENT RE- ;O.IZO
< f N orth Cerolins Dcparone s1 o IFavi mows sod hoard Rcaosecew Division of Wo rn' OueUny
WELL CONTRACTOR CERTIFICATION #
c A91tt COWTR/iCTOR: s. WELL DETAILS
f{ (v kr2 'au r!
B - a Tad Depth:
/ , !J R Di.m ebcn,;��!, —f((�"
wool codtamr v ants b. Woof Land (Bolo. MawitaPdar):• ! j / rt.
I4•.sodnj taint le II.bonc load whoa.
Well Contractor Coet(totty Nuts .._
/4 STREETADDRE83 I Lae, ' 6 . CASINO: Lo ni,rnckr
I
so , 1 .' • a. i / u. Caing Depth (i(140 - it. in
.1 ry a own a r • b. Caw log Raeoved A. _ ---. —• _ io.
tmel one e,onEer 172) 3� A Ve P& �, � 7. DISINFECTION: - _ .
7. WELL INFORMATION: (Amount of 03%1514 =Scum Itypoehlwtic 04 d)
SITE WELL ID a (ifopplie,>bl ,l.0pc - L SEALIN23 MATERIAL:
STATE WELL PERMIT 0 (if apppUc bk) _ nn
Nrat I' ra( a Conical
n4 CA l
s I npp .bl� s /• ! r• I o' 1a ' i b Ccocwt Id Wow _ Ib.
C01)NTY wt LL PERMIT (f Wow p4 Waucr gal.
DWQ or OTHER PERMIT a Ofappticable) 85Algain
WELLITSB (ClM. soplleabls oat): 04 cralrocks a oldontid Emaemb Ib,
btneietpal/Pybllc ;Mums iol+Ce.nmacial Ayr INN Igi SI PellcU�,
ammo Nation lir Ismlan � watts ga•
Other (del use) ,
3. WELL LOCATIONN:��,�
COUN..IY�u1I0e'- ADRANGLENAME 7 1tp ttwtcrWl
NEARESP TOWN% AO10RA1 —�
pow /Row NMr,110•6a..1:on unb. Satdi•i.:o, las No. PIM( 7ip Cada) 9. Q LA! TH0D OP EMPLACE E • C P 0J MATBR A : r
TOPOGRAPHIC/ LAND S8TTUi0: J ti,....
Slope v.ILry Fles Ridge Other i - - • Ja 1 �..,_...
(Circle Ippreprinc sacoi0 •
LATrrUDti Rallia. amok, mbta L.
LONCHTUDE _
*Ante coma WEL DIAGRAM: Draw a dcmllad sketch of the.weU in tai but of this
LatitudrAongitudgsourva GPS Topogrepbieanen Ibe themesp an depLLNdepth .ad (somas-ormesons w►y)rcawWes
(L ical kn of ten era b. SAoa 4 an o USGS tap() loop and ie the well, grivol lams.!, Ituuw4 of cant psrfnmtions. sad depths end
attacked re relrf eni Pot wins GPS) typos of 8U mskriula two.
4o, T'ACI L1TY• Too Mac ohm sown..lksru dye wall it IaC4ta Compbt* la In44 n r� p
(If a teaiaoiiiu wail. plop sa aveviate 4b watt away lefeniulion only.) 1 1. DATE WELL A BANDONF.DJ 74 / y — II
FACILITY ID /(if pNlrnblc) I DO ItG EEO Y CUMIN' TNAT THr3 WWII. WAS AHANIXJNIiO IN ACCORDANCE
NAME OF FACILITY _._ I SA NCAC 1C, WELL CONSTRUCTION STANDARDS, AND THAT A rah' OP
- •. - MIS R/1COP gyms E WELL 0
STREET ADD
- - _— ` • ..... HAS BEEN PR TO THE
Ow or Town Sons Zlp Cola -- °yaw 0 .. r
•.. •• • &ACTOR DA {Tf
4b. CONTACT nn OPLNYELL OWNER, •' / l _ . • OA 2' /i
N•+a al .-/ d Al � Vii' • v
T fl: or ' ATe ^-, t. • • N(N0T111 W81L • Te
I mo {'" � j - In 4 • pink well • • mat bows htdletdtel • • : numb numb •b•mm. Lirear,a:dmu.l rsu
S11L TADORIIS• ��!�� f � L7 f c. uww kb13A MAC IC.01
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/ Jy��� p J Pk h i t 0 1 OP1 413A nN0 711E W
t,`ip�ar79Wt ! PC n• ado _
A be • 6 lf?c'1
Pao coda - none
Submit a copy to tho eantcr and tho aiginol to Iho Dtviylon avatar Quallty wilhlt► 30 day,. Porn Gw-30
Attn: IoRttnation branag.atcn 16) 7 Malt gorvicc came - Raleigh, l 17699•1617. Phone No. (919)733-7m 5 oat 566. guy. 5/06
02/21/H 08:48
TOTAL P.05