Catawba_Well Abandonment_20221122

WELL ABANDONMENT RECORD For Internal Use ONLY:
•4
1.Well CoBtt►uctor Inforrtmtion: WELL ABANDONMENT DETAILS
K7a.For Geoprobe/DPT or Closed-Loop Geothernml Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name I l !p
%) 7c.Type of disinfectant used: 7
2.Quell Construction Permit#:VPa ,(— ��1 y 4�
1
List all applicable well corsstnrction pernrits r c UIC,County,State•variance,etc)ifLvtown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.,Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public ®/Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑ Sand Cement " z `11 ¢i. .
❑Industrial/Commercial r .(".��tz e E,os E-&Clay
❑Residenfial W ater Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri afion ❑ Specialty Grout NOV 2 2 2022❑Gravel
W Non- ate Supply Well:r
❑ Bentonite Slurry �LlUrer(explain under 7g)
❑Monitoring ❑Recovery,
Injection Well:
7E For each material selehted ari6ve,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7jg.Provide`a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) ❑Outer(explain under 7g) F✓L4zk ,t i .gi p 1/ '?C4
4kC`Ou(%,A, a lei) l_Aw� .Sin� j�,�l/�l� �C✓C�
4.Date well(s)abandoned: �J J C.
�d 9a�� �t fre u �� c%•l� .t���� .mot-,� i
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
�SCt� L-p-►�1 r��.c�L �� 5)�e,rllltj Aj� ��4Sign-afaccrl-tiffliedWell�. 3)_ a Physical Address,City,and Zi P Contractor or Well Owner/^ a�� Date
County By signing this form,1 hereby certify that tire well(s)was (were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.6100 or 2C.0200 Well Constntetion Standards
51b.Latitude and longitude and that a copy of this record has been provided to the well owner.
� in degi'ees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
9.Site diagram or additional well'details:
35.S'T 40 N ki, i 3`)CS You may use the back of this page to provide additional cell site details or%%vll
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF 3WMELLM BEIAG ABANDONED
Attach well commtchonrecord(s)tfavailable Formullipleiryectionornon-watersupplvt+elJs SUBMUTA_LINSTRUCTIONS
ONL I'with the saute constntcdon/abatrrlonmen;yott can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well MY: abandonment to the following:
Di-vision of Water Resources,Information Processing Unit,
6b.Total well depth: 1 (g,) 1617 Mail Service Center,Raleigh,NC 27699-1617
.� 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: ( ) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
[ 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft) abandoned.
Il
ft Screen length Cif known):
i
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources
� Revised 2-32-2015

CATAWBA COUNTY Case# WELL-09-2022-181445?
Public Health Departme R Subdivision AARON H LAIL
aQ Environmental Health Division PINi4I 460703144409
PO Box 389,25 Government Drive,Newton,NC 29658 LOT# 7
'w
Site Address: 3868 LANDMARK DR,SHERRILLS FORD NC 28673
Name on Permit: JONATHAN HART
Property Size: Acres 0.49
Directions: Hwy 150 to Litte Mt Rd,Little Mt Rd,to Landmark Dr,Property on Lakeside
Owner/Authorized Representative Acknowledgement of Permit Receipt
1!. _I certify that I am the owner or authorized agent(owner's authorization required)representing the owner of
11 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 RBPR-03-2021-37020,by the following method(s):
Received in Person
Facsimile Transmittal(Return form with signature required)
TElectronic 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 sp e.cifed under the
North Carolina Laws and Rules for Sewage Treatment and Disposal Systems(15A NCAC 18A.1900),
and/or Well Construction Standards(I5A 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:09/30/2022
Owner/Authorized Representative Signature
Date
Documentation of Permit(s)Transmittal
(permit transmitted by electronic or other means)
Permit transmitted by (name ofperson sendingpermet)
Signature Date/Time '01 10 7a
Method: Fax Email US Mail Other
Owner's request to send by the above indicated method of transmittal in lieu of signature
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We wantt tto hear from yoiPlease ttake a few momentts tto complette our custtbmer service survey att
http://www.surveymonkey.com/s/EHCusftomerSefvlce
brei%t6beast-ilne &-n
ietipnn"� 09/302022 09:30

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