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HomeMy WebLinkAboutWELL-11-09-2969.TIF A , `CATAWBA COUNTY Case # EHPR-11-09-2800 4 2 Public, Health Department Subdivision Environmental Health Division Section/B1/Ph/Lot# PO Box 3:59, 100A Southwest Blvd, Newton NC 1,84 2 srd (8'28) 465-8270 Fax (828) 465-8276 TDD (828) 465-8200 PIN# Applicant/Owner Shane Beal I / Site Address: 1.336 NW 6t St NW Property Size: Directions: WELL ABANDONMENT PERMIT WELL TYPE: DRILLED, BORED, DUG, ETC Bored '4ul- 'r"~ 11-23-09 ISSUED BY: PERMIT ISSUANCE DATE OWNER OR LEGAL REPRESENTATIVE DATE WELL ABANDONMENT INSPECTION TOP Y OF CASING MATERIAL REMOVED (BORED WELLS) YES NO ❑ WELL DISINFECTED: DATE INITIALS WELL FILLED WITH APPROVED MATERIAL (BORED OR DUG WELL ONLY) DATE L' 1-01 INITIALS {~P WELL GROUTED TO SURFACE (DRILLED WELLS ONLY DATE INITIALS WELL CAPPED WITH CONCRETE DATE INITIALS /?/0 WELL ABANDONMENT REPORT RECEIVED DATE INITIALS PERSON ABANDONING WELL OWNER DATE CONTRACTOR i1 o~ ft / Z tr DATE (Z 0 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. AUTHORIZED STATE AGENT COMPLETION DATE C:\Documents and Settings\jenglish\Local Settings\Temporary Internet Files\Content.OUtlook\PP8JW9G6\WELL ABANDONMENT PERMIT I I -09-2800.docx EHPR-11-09-2800 TRACKING INFORMATION Date Calls 11-20-09 1 Contact - Discussion Only 11-20-09 Site Ready to be Flagged 11-20-09 Site Flagged 11-20-09 Site Ready to be Evaluated 11-23-09 Site Evaluated 11-23-09 Approved for Issuance Other Date Comments/Field Notes FROM EETZER WELL CO FAX HO. : 704 434 6107 Dec. 02 200' 01:08P11 P1 ern. WELL ABANDONMENT RECORD r North Carolina Dep artrrtent of Environmcnt and Natural Resources- Division of Watcr lily WILL CON'MkCTOR CERTIFICATION ii Z_e 1, R'ELL ONTRACTOR: 6. WELL DETAILS: h:.~ ft. Dianne:er; in. Qr ~Pj/?~ : a. Total Dep. W I on (Individual} Name b. Water Level (Below Mes`suring Point); ! ft. _L._ e k l~ L _ Measuring point is C2 R above lar4 surface. Wcll Coruractor Company Nam, STREET ADDRES 73~~r' ice' 6. CASING: Length Diameter G a. Casing Depth (if known): ft. G ic. iry or Tmvn Stetc Zip Codc b. Casing Rrn ovcd: in. Ar,A.oC - one n . ber 7. DISLN'PECTION: r 2. W'CLL L1 FOWMATION: ) (Amount of 650/,75016 calcium hypochloritc umd) SITE WELL ID ft (ifapplit-sbl6 S. SEALING MATERIAL: STATE WELL PERMt1' # (ifapplieabkL Neat Cemrnt S d Ccrprp Cement~~ T~j~(' Cement J lb. COLIN'IY WELL PERMIT 9 (if applicable) Water /Rb(, Waur Pl. DWQ or OTHER PERMIT z (if applicable) $lplypire WELL USE (Circle applicable uso); Mnnitoriag Residential gentomte 16. Muoicipal/Pubfic IndustriaUCommercial Agricultural Rccavrry Inje oo ratio 7y pc:Slurty_Pellets- Other (list ttsc)-y~10,~o Water sal. Other 3. WELL T / COU1hiT'Y RAN c NAMf Type Mistrial NTEAREST TOWN': (D Mtou~t (StresaiR.oad Name, Number, Comtnurtiy. Subdivision, Cot No„ Parcel, Zip Cod,,) 9. E\PLAfN 6 TH OF E .La btE F pfq E TOPOGRAPHI M",Pa!e Slope Ridge Other le seuir,g) May be in dour a. LATTRIDE mitutec sacmtda, or u a LONGITUDE d=ined format 10. W ELL DIAGIL M; Draw a detailed sketch of the well on the back of this Latitude/longitude source: GPS Topoarephic map fore, showing total depth, depth end diameter of vcrecns (if any) remaining (Location of well attar De showr on o U GS ropo map and to the well, gravel interval, intervals of casing pen lions, and depths and ouaehed ra rhtr jorm (/not using GPS.) types of fill materials ua d da. FACILITY-Tlur n um of the business ohcr. thr, Well is located. Complete 6a and,:b. / O (]to residential well, skip aa; LSD{de <b. wetl over. mfomabon only.) 11. DATE WELL .\BnNDONED 91 FACILITY ID #(ifapplicable) I [)0 HER Y CERTTY AT THIS WELL W ABANWNFD t- ACCORDANCE NAME OF FACILrR' WITH l5 -CAC 2C, wE L NS RUCT10N ND DS. A14D THAT A COPY STREET ADDRESS THl RE 0P-ON NAISSREEF PR VMIZ:D TO t 1. V 1 T Cia or Town Stan Zip Code SIGNaI'tRtl OF CE lilED 'ELL COA C R ATE ab. CONTACT OH v1E LL 'Yip R: NAME v SIGNATURE OF V ATZ WELLOw'NERADA\IMNING THE WELL DATL i ~ (The F, are ue11 ..var wt be= ' 'vidual u•bo re-.,nally abandons biuLr, ssideadd well $ p /3 7 J maISA\'CAt 1I13.1 S I i,,9-* , d a Ct o{ o`k. / Zip Code PWTED NAME' OF FCASON AHANDONr:rG THE WELL Area ode Phone n e Submit a copy to the owner and the origioal to the Division of Water Quality withie 30 days Form GW'•30 Arta: Information Mawtgement 1617 Mail Scrvlee Cea ter -Re le;eh, NC 27699-1617, Pheae Nn. (919) 733-7015 ext 568- Rev. 5/06 FROM SEVER IJELL CO FAQ( NO. 704 434 6107 Dec. 02 2009 01: ©9PM P1 - jrx~ o I H