MO-5492_19126_CA_WR_20230403_AbandonMW-3A

WELL ABANDONMENT RECORD
5. WELL DETAILS:
a.Total Depth:____________ ft. Diameter:____________ in.
b.Water Level (Below Measuring Point): _________ ft.
Measuring point is _________ ft. above land surface.
6. CASING:Length Diameter
a. Casing Depth (if known): __________ ft. ________ in.
b. Casing Removed: __________ ft. ________ in.
7. DISINFECTION:_____________________
(Amount of 65%-75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement _________ lb. Cement_________ lb.
Water___________ gal. Water___________gal.
Bentonite
Bentonite lb.
Type:�Slurry �Pellets
Water______________ gal.
Other
Type material _________________________________
Amount_____________________________________
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
10. WELL DIAGRAM : Draw a detailed sketch of thewell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsused.
11. DATE WELL ABANDONED ______________________________
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCEWITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OFTHIS RECORD HAS BEENPROVIDED TO THE WELL OWNER.
___________________________________________________________________________SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
__________________________________________________________________________SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE(The private well owner must be an individual whopersonallyabandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
________________________________________________________________________
PRINTED NAME OF PERSON ABANDONING THE WE LL
SITE WELL ID #(if applicable)____________________________________
STATE WELL PERMIT #(if applicable)____________________________
COUNTY WELL PERMIT # (if applicable)_________________________
DWQ or OTHER PERMIT # (if applicable)__________________________
WELL USE (Check applicable use):�Monitoring �Residential
�Municipal/Public �Industrial/Commercial �Agricultural
�Recovery �Injection �Irrigation
�Other (list use) _________________________________________
3. WELL LOCATION:
COUNTY______________ QUADRANGLE NAME _______________
NEAREST TOWN: __________________________________________
___________________________________________________________
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
�Slope �Valley �Flat �Ridge�Other_____________________
(Check appropriate setting)
4a. FACILITY -The name of the business where the well is located. Complete 4a and4b.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable) _________________________________
NAME OF FACILITY_________________________________________
STREET ADDRESS __________________________________________
___________________________________________________________
City or Town State Zip Code
4b.CONTACT PERSON/WELL OWNER:
NAME ____________________________________________________
STREET ADDRESS___________________________________________________________________________________________________
Form GW-30Rev. 5/101617 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone]
Submit a copy to the owner and the original to: Division of Water Quality -Information Processing,
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # ___________________________
1. WELL CONTRACTOR:
_________________________________________________________Well Contractor (Individual) Name
_________________________________________________________Well Contractor Company Name
_________________________________________________________
Street Address
_________________________________________________________City or Town State Zip Code
(_______) __________________________
Area code Phone number
2. WELL INFORMATION:
LATITUDE _______°____'_________" DMS OR _____________ DD
LONGITUDE ___ ___°____'_________" DMS OR _____________ DD
Latitude/longitude source: ⃞GPS ⃞Topographic map
(location of well must be shown on a USGS topo map andattached to this form if not using GPS)
2003 West C Street