The URL can be used to link to this page

Home My WebLink AboutWELL-2-11-15142.TIF �gA CATAWBA COUNTY Case # WELL-2-11-15142 ��:� G� Public Health Department Subdivision & a Environmental Health Division av ''�' PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # �842 5M PIN# 360901167925 ApplicantJOwner NEILL GRADING & CONSTRUCTION � �„�P� _ �_� ( .R� �(� Site Address: BLUE STAR RD, HICKORY, NC Properly Size: SF 45.319 ACRES Directions: HWY 127 S LEFT HUFFMAN FARM RD, RIGHT PITTTOWN RD, RIGHT ON BLUE STAR, AT END OF ROAD WELL ABANDONMENT CERTIFICATE OF COMPLETION Well Type: Dug - � INSPECTIONS � INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR �' INSP-119881 04/08/20ll EH Well Abandonment Observed Annroved Megen McBride INSP-119882 04/08/2011 EH Well Abandonment Site Inspection Annroved Megen McBride INSP-119883 04/25/2011 EH Well Abandonment COC Annroved Megen McBride INSP-119884 04/25/2011 EH Well Abandonment Report Received Annroved EH Admin INSP-119885 04/08f2011 EH Bored Well-Top 3 ft Casing Removed Annroved Megen McBride INSP-119886 04/08/2011 EH Well Disinfected Annroved Megen McBride INSP-119887 04/08/2011 EH Well filled with approved material Annroved Megen McBride INSP-119888 04/1 1/201 1 EH Well Capped with Concrete Annroved Megen McBride Contractor - Jan - Neil Grading 04/08/2011 ABANDONED BY DATE OBSERVED Megen McBride 4/25/2011 AUTHORIZED STATE AGENT APPROVAL DATE 04/26/2011 1021 „gA • CATAWBA COUNTY Case # WELL -2 -11 -15142 Public Health artment Environmental Dep Health Division Subdivision V PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot # /8.2 sw PIN# 360901167925 Applicant/Owner NEILL GRADING & CONSTRUCTION Site Address: BLUE STAR RD, HICKORY, NC Property Size: SF 45.319 ACRES Directions: HWY 127 S LEFT HUFFMAN FARM RD, RIGHT PITTTOWN RD, RIGHT ON BLUE STAR, AT END OF ROAD WELL ABANDONMENT PERMIT Wells shall be abandoned in accordance with state regulations: Article 15A North Carolina Administrative Code Subsection 2C The Well Abandonment Report must be submitted to the Catawba County Environmental Health within 30 days upon completion of a well abandonment. Well contractor must schedule well abandonment inspection with Catawba County Environmental Health. WELL TYPE Dug Megen McBride 02/11/2011 ISSUED BY PERMIT ISSUANCE DATE 02/11/11 11:34 , CATAWBA COUNTY Case # WELL -2 -11 -15142 G Public Health Department Subdivision Environmental Health Division d 's' PO Box 389, 100 -A Southwest Blvd, Newton, NC 28658 Lot # t8.2 w P1N# 360901167925 Applicant/Owner NEILL GRADING & CONSTRUCTION Site Address: BLUE STAR RD, HICKORY, NC Property Size: SF 45.319 ACRES Directions: HWY 127 S LEFT HUFFMAN FARM RD, RIGHT PITTTOWN RD, RIGHT ON BLUE STAR, AT END OF ROAD Owner /Authorized Representative Acknowledgement of Permit Receipt I certify that I am the owner or authorized agent (owner's authorization required) representing the owner of the property described above. As the property owner or authorized representative, I have received the above referenced permit(s) as requested in the application for service EHPR -2 -11 -9276 , by the following method(s): Received in Person Facsimile Transmittal (Return form with signature required) Electronic Image Transmittal/ E -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 (15A NCAC 2C .0100), shall apply to the issuance of this permit and the construction of the wastewater system and /or water supply well permitted. Permit Issue Date: 02/11/2011 Owner /Authorized Representative Signature Date Documentation of Permit(s) Transmittal (permit transmitted by electronic or other means) Permit transmitt by (name of person sending permit) Signature , ik / i Date /Time , -:- 91 '/ 1 1 Method: Fax Email US Mail Other Owner's request to send by the above indicated method of transmittal in lieu of signature acknowledges the conditions and statements above. ,30,1 Gned/5/ d ;�,y. Ctlrr1 02/11/11 11:34 , � vf:,sY�TA, Wel1 2-i 1- t si42 E EIVE . . ..� . `` r~ ° �.�� 1�' �` s WELL ABANDONMENT RECORD qp t � . '>� �� k_r a2 Norll� Carolina Department of Environment and Natucal Resources- Division of Water Qualih• h�f � G�� 201� � .,- . -- WELL CONTRACTOR CERTIFICATION # G� G ��/} 1. WELL CONTRACTOR: 5. R'�LL llETAILS: E��R��NTA�. H�LTH �- n � �� ' "��'�'�� y' a. Total Depth: Z� ft Diameter:��. Well Contractor (Individual) Name b. Water Level (Below Measuring Point): %� ft. �� f\,�'� �ti+-' •� Measuring point is L7 � ft above land surface. Well Contractor Co�pany Name , ' STREET ADDRESS �,� /_�� c, s/4� � f 6. CASING: Length Diameter �!K! f i% Li ti� �� S Z a. Casing Depfh (if ]mown): __�_ ft. in. City or T wn Sfate Zip Code b. Casing Removed: Q ft in. �� f � i� .> u �� -! � l�5 !� � �. �� e.�e ct � � t �� 115 '70 - � � 2i nr c°��n� Area code - Phone number 7. DISINFECTION: // �� r � 2. WELL INFORMATION: � / (Amount of 65%75% calcium hypochlorite used) SITE WELL ID#(if applicable) !�/�� 8. SEALWG hSATERIAL: STATE WELL PII2MIT #(if applicable) /✓`�— Neat Cement Sand CemPnt Cas�' � ' Cement 16. Cement�A9. � C�fVY"�C PERMIT # ifapplicable) U1C1�` Z S/� Z Wat� gal. Water gaL� p,n�3t 3�mo�oit(��19ZS DWQ or OTHER PERMIT �! (ifapplicable) �/{- Bentonite WELL USE (Check appGcable use): ❑ Monitoring [� Residential Bentonite Ib. ❑ MunicipaUPublic ❑ Industrial/Commercial ❑ Agricultural Type: �Slurty ❑Pellets Water gal. ❑ Recovery ❑ Injec[ion ❑ Irrigation ❑ Other (list use) Other Type material / �� l(G(/ 3. WELL LOCATION: Amount �`t' 77� �i(. S COiJN1'Y t:� �'v.i,�j�t QUADRANGLE NAME ('� i 1.I1�� I1J C - NEAREST TOWN: E�-{ (�{ 9. EXPLAIN MEl'HOD OF EMPLACEMENT OF MATERIAL: °-�,�° �t c1;. 6..v (Street/Road Name, Nurttber, Canmiauty, Subdivisiox� LotNo., Parcel, Zip Code) TOPOGRAPHIC / LAND SE'I"I'ING: � Slope ❑ Valley ❑ Flat ❑ Ridge � Other (Check appropriate setting) � �, 10. WELL DIAGI2t1M: Draw a detailed sketch of the well on the back of this �° —y �j � May be in degrees, foan showin total d th, d th and diameter of screcns if an remainin LATI"ITIDE /��5_ O ✓� • O �� seconds, or in a g � � � y� g I.ONGIT[IDE �t�/ �� QU, Z�� decimal�£oanat in the well, gravel interval, intervals of casing perforations, and depths and —" L / types of £ill materials used. Latitude/longitude soarce: �GPS ❑ Topographic map v (Gaeation ofwell murt be shown on a USGS topo map and 11. DATE W ELL ABANDONED 0 �� anached to this form ifnot using GPS.J I DO F�?REBY CERTII�'Y T'HAT THIS WELL WAS ABANDONID IN ACCORDANCE 4a. FACILITY- The name of the btainess where the well is located. Complete 4a and4b. WITH I SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND TIIAT A COPY OF (If a residecrtial well, skip 4a; comple[e 46, well owner information orily.) THIS S BEEN PRO VIDID TO THE WELL OWNEf2_ FACILITY ID #(if applicable) NAMEOFFACII,ITY ��U�k f'Gf v�-- / /< (� GNAT OF TIFIED WELL O1VT OR " DATE STRBET ADDRESS J � �� -FO ✓� �- ��-�-� r�o< �- N L � Cdy or Town Statc Zip Code SIGNA OF PRIVATE WELL OWNER ABANDONfNG TEIE WELL DATE 4b. COIVTACT PERSON/�l'ELL OWNER: (The_gu te well owner must be an individual who personallv abandons his/her Iesidential well in accordance with ]SA NCAC 2C .0113.) NnME y�r��/�:.� U,`l l�c e, LC. C. 5�,�( 1,i1 _ j2� �/1i1 v� i Q/� STREET ADDRESS /', D, /� (�( �� PRINT�ED NAME OF PERSON ABANDO THE WELL /� �� C- Z ��1� Submit a rnpy to the owncr and the original to tlie Division oC Water Quatity within 30 days. Porm GW-30 Attn: InCormation Management, 1617 Mail Service Centcr —Raleigh, NC 27699-1617, Phone 1�To=•( 19) �1 •� Rev. 5/06 �J � � _ ca c�� J / n � (�� \��1.'� I Y Y�ti I�J I � � �`�- �- � /�-�- EL �C��>C� ��C'{�'�� U.c �� <<.G.�� , ti � �.� �°--�-, ��, l. v. � e � ( ca��;��.��-z_<<_,s;�z � Y �._----- 5 ' J G �cl� ��e ( � '� � � CO r , �.c� � � d ,p 'Q .� ; � , � � � A � � � , � `-� �- 11 ,� -----�' 4 Y _,_. ��xlz'—► /�1 � w e I I i �`c s. j� o, �i � �� (.�.?e I ( . � 1� T 5 t DL w�1 �t_.5 . Rz,� c�� ►�� _ -- _ � ,�+` 2 � ' �i'� �.I �-�.,c � �i�.� ��d�� C�.�. �� :j.,�. �� hR- I n� L �� , .