HomeMy WebLinkAboutWELL-2-11-15513.TIF �$ CATAWBA COUNTY Case # WELL-2-11-15513
G Public Health Department
Q 2 Subdivision
a Environmental Health Division
v v� ''�' PO Box 389, 100.A Southwest Blvd, Newton, NC 28658 Lot #
�g s" P�# 46070ll94431
ApplicanUOwner RICHARD DAVIS �7
Site Address: 7050 CAMP DOGWOOD DR, Sherrills Ford, NC ��p� _�- i� r � y `
Property Size: SF 36.49 ACRES
Directions: MOUNT PLEASANT RD BETWEEN SHERRILLS FORD RD AND LITTLE MOUNTAIN RD
WELL ABANDONMENT CERTIFICATE OF COMPLETION
Well Type: Bored -
INSPECTIONS
INSPECTION# COMPLETED INSPECTION TYPE STATUS INSPECTOR �.
INSP-123228 04/08/2011 EH Well Abandonment Observed Annroved Robbie Phelps ='
-�..
INSP-123230 04{1112011 EH Well Abandonment COC Annroved Robbie Phelps �
INSP-123231 04/08/2011 EH Well Abandonment Report Received Annroved Robbie Phelps
INSP-123232 04/08/2011 EH Bored Well-Top 3 ft Casing Removed Annroved Robbie Phelps
INSP-123233 04/08/2011 EH Well Disinfected Annroved Robbie Phelps
1NSP-123234 04/08/2011 EH Well filled with approved material Annroved Robbie Phelps
INSP-123235 04/08/2011 EH Well Capped with Concrete Annroved Robbie Phelps
Contractor - Jeff Speagle 04/08/2011
ABANDONED BY DATE OBSERVED
Robbie Phelps 4/11/2011
AUTHORIZED STATE AGENT APPROVAL DATE
04/11/2011 16:34
�gA • CATAWBA COUNTY Case # WELL - - 11 - 15513
,', Z Public Health Department
Environmental Health Division Subdivision
' PO Box 389, 100-A Southwest Blvd, Newton, NC 28658 Lot #
18.2 ,w PIN# 460701194431
Applicant/Owner RICHARD DAVIS E1/ DR _ o - f gto
Site Address: 7050 CAMP DOGWOOD DR, Sherrills Ford, NC /
Property Size: SF 36.49 ACRES
Directions: MOUNT PLEASANT RD BETWEEN SHERRILLS FORD RD AND LITTLE MOUNTAIN RD
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
Bored
Robbie Phelps 02/23/2011
ISSUED BY PERMIT ISSUANCE DATE
02/23/11 10:01
///
�j , � J� 7 �G.� .
� w( .� � ; WELL ASANDUNIYIENT RECORD
�° �. `: North Caro[u�a Depamneni of Enviavnrnent and Naau�al Rcso�sccs- Division of Warer Qualizy
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WELL CONTRACTOR CERTIFICA'�'ION #� d� � Q9 �
l. WELL CON7RAC7'OR: � �� ��,
"— !� .� G �. so�t n��,:_�_ fi. n�:�� ;n.
weu co�rtraaor (fn�iv�al> Naa� b. water Level (Bclaw Pai� -
�G, �.�. � /� Q � ( �� ����� ; �� n � � t. _S�� fc.
(� Y�` � l� �.C�� V � Mcasuring point is 7'CJ }"' Ct above !and surFacc_
Well Comractor Company Name --`�—
sr,�rAnnxFSS Co � �o �Dc� (P�,� C � �. cnsnvc: � �;���
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Gry or Tawn Statc Zip Codc b_ �_
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Area coc�c - Pfto� nuu�tur 7. DiS1lVFELTlON: �. �� ���.
2. W£LI. IiVFORi�'L4TION: f'� .,, I � I �� ' � (Amouui of 65'l0-75% c2lcium 6yparfillorile nsed)
SITE WELL ID#lifapplirab2c) �'� ~ 8. SEAI.DVG MA7FRIAL-
STATE WELL PERMIT �(ifapplicabk lNest Cement Saud Cemeet:
C�mrnt �r�f r� C�ent lb.
COUNT'Y WELL PERlVIi7' #(ifapplicable) bYater ga6. Waser gai.
DWQ or OTHER PERMiT k(if applicabte) Benrflaue
WELL USE {Circic appticabic �e)_ Monitormg ResiQeatiay
moo:cipauPan6� �namu;aircammeraat agr;c�n, Benconiu l 6� �b.
Recovery injc�n lrrigatien Typc Slarry_ Pdlets_
Other (iisc usc) wa� gat.
Other
3. V6�ELL LOCATlUN:
COUNTY CCL"�'�l�I� c�UA�RANGL£NAME T ��
NEA3tFS'rTOWN- S�l� l�!`� ��$ �0/�}' q� '
(SueeuRoad Nam� 1Vumbcr. C�y. Scbdivisiva I.at ivo_ Pacet Z'iv Codc) 9_ EXPLAIN METHOD OF EMPLACEME(VT OF MIATERIAL:
TOPOGRAPHIC ! LAND SETTIIVG. {` G G � e�� �'Q L d C LC�, l�
sio� v��ey � x;a� ocher � �('� 1.,.� �,�(--t� ar� �/`G-"r
. (Cu�le aPP� �S) --°
'� e � G� May bc ia degxs, - A'� C� CV �`..C. c� ��� Q/}� 1•� '
LA'ff�'UDE � �J � i
��s. secoods. or m a
LONGITUDE �� � e �? �cimal ioimai I� WEI.L DIAGRAM: Ihaw a dcxaz�ed sketch of 8ic well on the back of this
L.atiQtde/longihtde SourCe: GPS TopographiC map . form show�g wta[ depth. dcFtb aad � of saa,us (if any) remaining
(Location oJtiveU mnst be shou�n on a USGS �opo mvp and in tht wtU, gtavel iatetva[. intuvats of cat�g Perfora�ions. aad depths aQd
attached to this jorm Ffno� rrsing GJ'�J types af fill matrrials �.
4a FACILITY- Tfx umne of the b�s wkce thc uz11 's loca[ed. Co� da a�46. j j
f tf a rcs�6a1 � s�dP 4a: campkte 4b. we0 owna iaf�mation ontR) l l. DATE WELL ABAPIDUNED ��
FACILTf'Y ID �(if appiicabk}
I DO E�REBY (�1t7iFY'IHAT THIS WEI.L WAS ABAND(}NE[9 BV ACCORDANCE
NAM£ OF FACii.1TY �17iT�3 i5A AtCAC �. WELL (,1p�$7RU�pN �-q�q� ��T A COPY OF
STREET ADDRESS THIS RECdRD PROYIDED TO 7t1E WII.L OWA(ER.
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, c�ry ot Town . 5� z� coae s�cav�a co a arE
4b. CONTACT PERSON/Vl+Ei.i. pWtVER: �
NAME ► �E.JC� 4� SIGNATEtBE TE ABANDONIN6'I'HE WELL DATE
STREET aDDRESS �C:� � U �� t'�1,� c� G�dc�d C1� P�e msac lx aa mdividuat who, na�w zb�da,s tti�ha r�sidemia� wcu
m� [SANCAC .OIt3.)
� � P r, � �5 �l'� t� C a �,�'7 � E'_- � � �
c,ry or ro,vu ssa�e z.;p coae , �nv'r�o na,� oF �v c r�E wEU.
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�aA . CATAWBA COUNTY Case # WELL -2 -11 -15513
T G P ibl ic Health nvi ronmental Departme Di vision
E AR
Subdivision
E
d 0 PO Box 389, 100 -A Southwest Blvd, Newton, NC 28658 Lot #
/g.2 sM PIN# 460701194431
Applicant/Owner RICHARD DAVIS
Site Address: 7050 CAMP DOGWOOD DR, Sherrills Ford, NC
Property Size: SF 36.49 ACRES
Directions: MOUNT PLEASANT RD BETWEEN SHERRILLS FORD RD AND LITTLE MOUNTAIN RD
Owner /Authorized Representative Acknowledgement of Permit Receipt
_.1 certify that 1 am the owner or authorized agent (owner's authorization required) representing the owner of the
property described above.
,.)--ItO 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 -9470 , by the following method(s):
g o 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: 02/23/2011
Owner /Authorized Representative Signature /� 7 ._
Z
Date 2 - 21 - I (
Documentation of Permit(s) Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name of person sending permit)
Signature Date /Time
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.
02/23/11 10:01