HomeMy WebLinkAboutWELL-2-10-4430.TIF
CATAWBA COUNTY Case# WLS2009-00152
Public Health Department Subdivision
Q _ Enviromnental Health Division
ar PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Sect/BL/Ph/Lot # 74&AD
2 ,(828) 465-8270 FAX (828) 465-8276 TDD (828) 465-8200 PIN4 460702557702
Applicant/Owner ROBERT PHILLIPS
Site Address: 3743 REID CIR SHERRILLS FORD NC
Property Size: SF .7 ACRES
Directions: 16S/ LF CAMPGROUND RD/ TURN LF SHERRILLS FORD RD/ TURN LF BEATTY RD/ TURN LF REID CIRCLE/
WHEN YOU COME TO Y IN ROAD GO RIGHT APPROX 1 MILE ON RIGHT
WELL ABANDONMENT PERMIT
WELL TYPE (DRILLED, BO DUG, ETC):
U N DATE
ISS[JE PERMIT I,
/ C/
.ca
OWNER OR LE AL REPRESENTATIVE D L
WELL ABANDONMENT INSPECTION
TOP Y OF CASING MATERIAL REMOVED (BORED WELLS) YES NO
WELL DISINFECTED DATE INITIALS
WELL FILLED WITH APPROVED MATERIAL DATE INITIALS
(BORED OR DUG WELL ONLY)
WELL GROUTED TO SURFACE (DRILLED WELLS ONLY) DATE INITIALS
WELL CAPPED WITH CONCRETE DATE INITIALS I i
WELL ABANDONMENT REPORT RECEIVED DATE L ~-7'10 INITIALS
PERSON ABANDONING WELL
OWN R DATE
CTOR DATE/ f~
Wells shall be abandoned in accordance with all state and local regulations and rules. The Well Abandonment Report must be submitted to the Health Department
within 30 days upon completion of a well abandonment.
C-~ Z - - p
AUTHORIZED STATE AGENT COMPLETION DATE
T dcmurk f t rm.+fivisapp rp 03/23109 1628
CDP File Number: 29585 County File Number: wLszoo9 00152
Drawing Type, Construction Authorization Date: 0 4 1 3 /.a,0.0.9
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Page 3 of 3
PAGE 01
02/02/2010 23:23 747x89247135 3 K I:JELL DPILL
UOVED"
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HEALTI-P
North Carolina Department of Environment and Natural Resources- D{visi.on of aY atit
WELL CONTRACTOR CERTIFICATION 13266
L
g, WELI, DETAILS* P 1
1. WE LL (':ONT .4(.T0 R: s y
~5 - ft. Diametcr: - to )
Alfred L Kiesling Jr a Total Depth: _
o
_ / ft
\>'ell C:dntnetor I Ind) -)dual) Name - b Water Level (Below PAe ring Point) t;n w 1
Mensonng point is ft- above land Surface
E3 & K Well Drlllinq Inc
\'etl Contra. for Cmtioany Name l.crtgih Diameter
132 Mt. MourneLp - 6. cASINC::
STRr•,tt? nDL'7RItSS - -
r t h.
NC n Gating Depth (if bwwn): in.
28117
MOogeSVllle - ft ~j'T in
- (f'tr\- or l'p.rn State 7tp Code b. Casing Rzinoved:
704 892-4696
7. DiSINP ~2-`~ A
Area c'bde - Phonr. nurnber 'ECTION:
(.Amoum. of 65%05eb calcium h}p(tchlonte aced)
2. WELL INFORMATION:
8. SEALLNG MATERLAL.
SITti 4 Ei.l. 11) a (i1'applicablc)
yLtJCU=" SxnA Cement
$TA"CE wF.Li. PERMIT y I t(applicahlc) -
n nc~ _ Cement lb Cement-_- lb.
('C1ItdTY't1'F.Lt: PERMIT it (irnpphcahlc'
[TwQ br OTHER PYRNIIT ft (if applicebk) >~1pt2n~Lti
$enioniie lb.
\YELLI IISF'. )(:heck npphuhlc use) Monitoring ;KRa+IdenAal
T}•pr ❑Slum OPallets
❑ MinkipehFublic U Industrial/Commcreial ❑ Agrieukural
Water-, - gal.
F-j Rc6nery (7 Injection ❑ Irrigation QluL
❑t7liicr dial ucrl . - C~.~.C.
TYPc material
3. R'ECI, L(K .t'f10N: Amount
COUNTY C4.-}tu b. QUAP.RANW.F 1JAMF M -
NE..4RF,ST 7r)W 3~_r~ ll~,v~ - 9. EXPLAIN METHOD F k:MPLAC£MENT OF MATERIAL:
iStreo/Rmad Netn~. Numb«, (Comnltlnin', Subdi,-mon, Let No,, Parcel. Zip Cude)
T(~PCx~RAI>lnr ~ LANU Sr.TTMt3 „
❑51opc ❑V111ry 2T.lat ❑Ridge,0Olher- - -
(Check apprnpnxte setting) 10. WELL DrAGR01: Draw a detailed sketch of the welt on the back of this
Ede6m-l m, form showing anal depth, depth and diameter of screens (if 2FV) remaintnc
l.;~TI i l)I)N ds, o Ina in the tve11, gravel mtcrval, intervals of casing, pcrt'orations, and depths Ind
" l
types of all materials turrl
l wttiude/tongHude tourcc: ❑ GYS ❑ Topographic map II DATE WELL ADANDONED _ =A-9-- L D
Ojwatlna eif".-ell mucl he thnw•n on o USG.S rppo map o-Y
attached In thif farm if nor vsitq (.;PS) I DO HFUBY CERTIFY THAT 7141S uVFU- WAS ,BANDONTO IN ACCORDANCE
11,;q 15A. the name otthe Mt6inese ,,here the well is locered C<o"Plme 44 anddb. T (.O D LHAS BEEN Ptt D D TO TW. ~ E J D. 0w4r K Nn kY a COPY OF
lira rc!j4tnfigl well, •,kiy 4a: fNnplete ib. Foil nwnrr uslitrmation (mh' )
F,kellj1.), IT) ;Iifappllcohtc) I - r a
hlAtttf. (?k 4(u.iTl' sIGNA R , OF CER" IF ED t ~VLLCU'T CTO D.ATF.
_ S1GNA(URE OF KIVATt WELL OWNER ABANDONING THE WELL DATE.
Cm or Ymvn State Zip Code abandons ht+hcr reside aunt w 1
(The private aeU rywnttr must be un tnd;aidual . hoIY
Jib. CONTAC ERSONn<'EL wNER: in accadarcewith ISA)4CAC2C 0113.)
N.4MF. 7_._F~......-. 1•RINTED I~,~Mfi OF PERSON AtWfv'DON NG THE ~'F.LL
- Fonn G W -llj
Submit n copy to the owner and the original to the Division of W oter QuaUty within 30 days' Rev. W
Attn: Information Management, 1617 Mail Service Center - Raleigh, NC 27694.1617, Phone No. (919) 733-7015 text 568.