HomeMy WebLinkAboutWELL-2-10-4881.TIF
G CATAWBA COUNTY Case # - j
Public Health Department Subdivision
U Environmental Health Division Section/BI/Ph/Lot# P-f .2 d b
PO Box 389; 100A Southwest Blvd, Newton NC
.184 2 s►+ (828) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 PIN# 3-7,32- q • _ 3 0
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Applicant/Owner F flermav\
Site Address: 3 j 5A. T
Property Size: 2- ire
Directions:
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WELL ABANDONMENT PERMIT
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WEL TYPE: DRILLED, BORED, DUG, ETC
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ISSUED A/~''~/j~~, PERMIT ISS A C DATE
OWNER OR LEGAL REP ENTATIVE DATE
WELL ABANDONMENT INSPECTION
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TOP 3' OF CASING MATERIAL REMOVED (BORED WELLS) YES ❑ NO ❑
WELL DISINFECTED: DATE 2 p INITIALS
WELL FILLED WITH APPROVED MATERIAL
(BORED OR DUG WELL ONLY) g~ t VS DATE INITIALS
WELL GROUTED TO SURFACE (DRILLED WELLS ONLY DATE 2 19 INITIALS A&n
WELL CAPPED WITH CONCRETE DATE L INITIALS (✓~^►Vl.
WELL ABANDONMENT REPORT RECEIVED DATE Zy )v INITIALS ~l^N~
PERSON ABANDONING WELL
OWNER DATE
CONTRACTOR Nil' V1- Kor il(ih DATE 2,6110
Wells shall be abandoned in accordance with all state and local regulations and rules. The Well Abandonment Report must be
sub t pd to the Hthin 30days upon completion of a well.
J2-1 b
AUTHOR Z STATE AGENT COMPLETION ATE
:\Documents and Settings\mmebride\Desktop\Permits & Memos\WELL ABANDONMENT PERMIT. docx
Feb 24 r10 01:16p Dan Huffman 828.397.6701 p.2
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WELL ABANDONMEN'T' RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3692-C
1. WELL CONTRACTOR: 5 WELL DETAILS:
William Joe Mull a. Trial Depth: 59 ft. Diameter: 6 in.
Well Contractor (individual) Name b. Water Level (Below Measuring Point): 31 ft.
Hickory Well Drilling; Co., Inc. Measuring point is 2 R above land surface,
Well Contractor Company Name
STREET ADDRESS P- 0. Box 4216 6 CASING: Length Diameter
Hickory N. C. 28603 a. Casing Depth (if known): Unknowm. 6 in.
City or Town Stato Zip Code b. Casing Removed: 2 R. 6 in.
8( 28 ).324-0035
Area code - Phone number 7. DISINFECTION: Chlorine Granules 8 Oz.
2. WELL INFORMATION: (Amount of65a/,75%calcium hypochlorite used)
SITE WELL ID N (ifapplicable) S. SEALING MATERIAL:
SPATE WELL PERMIT 4 (ifapplicable) Neat Cement Sand Cement
Catawba
EHFR-2-10-3917 Cement lb. Cement lb,
COUNTY WELL PERMIT N (ifapplicable) Water gal. Water r gal:
DWQ or OTHER PERMIT b (if applicable) Bentonite
WELL USE (Circle applicable use).- Monitoring Residential
MunicipaVPublic Indusirial/Commercial gnca ura Bentonite 8e0 lb.
Rec(n-M Injection Irrigation Watte:er 79- SluPellets X
W gal.
Other (list use)
Other
3. WELL LOCATION:
Type material Concrete
COUNTY Catawba QUADRANGLE NAME 40 Lb-
40 Lb_ Ready Mix
NEARESTTOWN: Conover, N. C. 28613 Amount
1304 1st. Street West
(Slrcet/Raad Name, Number, Cmummity, &abdivisims, Lat Na., PurW, Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TOPOGRAPHIC ILAND SETTING: Bentonite Poured from Top
slope Valley Flat Ridgc Other Two Foot Concrete Plug a :Top
(Circle appropriate setting)
May be in degrta,
LATITUDE N 35° 43.203' mirmtes.mcends.orina
LONGITUDE W 81 0 14-772' decimal format 10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
LatitudeAcingitude source: GPS Topographic map form showing total depth, depth and diameter ofscreerts (ifioy) remaining
fLocodrin oJHell anal be shoty#W5 USGS ropo map and in the well, gravel interval, intervals of casing perforations, and depths and
anached to rhi3fonn iifnar using GPS) types of fill materials used.
4a. FACILITY- The name ofthe business where the well is locatul. Compicie 4a mcHL 2/1912010
(If e rmidwtial well, skip 4a: complete 4b. well owner information only.) 11. DATE WELL ABANDONED
FACILITY ID N(ifapplicable) NIA
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY WITH 15A NCAC 2C, WELL CONS UCTION STANDARDS, AND THAT A COPY OF
THIS HAS BEEN PR VI D TO THE WELL OWNER.
STREET ADDRESS }
l 2- Z3 1~
City or Town State Zip Code SIGNATURE OF CERTIFIED WELL C TRACTOR D
erman s t Daniel / F. Huf man, xecl.
4b. CONTACT PERSON/WELL OWNER: Hen H1
NAME Henry E. Herman Estate SIGNATUREOFPRIVAT WF.LLO ABANDONING THE WELL DATE
Spaniel F. Huffman, Executor (Tbcpritzrewdlawnercnustbeaniodrvtdualwhona, llyaMndonsAaficrrrsidmrialwll
STREET ADDRES in accordance with 15A NCAC 2C.0 113.) Baker Rid. Cpnover N. C. 28613 William Joe Mull
City or Town Stale Zip Code PRINTED NAME OF PERSON ABANDONING THE WELL
Sf 28 312-0698
Area code - Phone number
Submit a copy to the owner and the original to the Division of Water Quality within 3D days. Form GW-30
Atln: lorormation Management, 1617 Mail Service Center-- Raleigh, NC 27699-1617, Phone No. C919)733-7015 cat 568. Rev. 5/06