Polk_Well Abandonment_20220601

North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section-1636 Mail
Service Center-Raleigh, NC 27699-1639-Phone No. [phone]
WELL ABANDONMENT RECORD WELL CONTRACTOR__IQMe,5 Cod Pre (& SR
WELL CONTRACTOR CERTIFICATION#�y 9 3 — A
1. WELL USE (check Applicable Box): Residential ❑ Municipal ❑ Industrial ❑ Agricultural ❑ Monitoring ❑
Recovery❑ Heat Pump Water Injection ❑ Other ] If Other, List Use:�y 11J UAR-,1 0r, IV-)3I.Q-VAJ
2. WELL LOCATION: (Show a sketch of the location on back of form.)
NearestTown:`YiRuo1J County UkM pOL�
►a M� wJJoOD' 1-�
(Road Name and Number, Community, Subdivision, Lot No.) Quadrangle No.
3. OWNER: R�i4lC� WELL DIAGRAM:Draw a detailed sketch of the well
i
showing p h and diameter of screens
4. ADDRESS: _I_ D A �d� remaining total depth,depth g in the well,gravel interval;intervals of casing--
\1
perforations,and depths and types of fill materials used.
5. TOPOGRAPHY: draw, slope hillto valley, flat
(circle one)
6. TOTAL DEPTH; ILQ � DIAMETER
7. CASING REMOVED:
feet
j diameter O L)
C
8. DISINFECTION:_ 0 z-
(Amount of 70% Hypochlorite used:)
9. SEALING MATERIAL:
Neat Cement Sand Cement
bags of cement bags of cement
gallon of water '7 gallons of water
Other
Type material
Amount
10. EXPLAIN METHOD EMPLACEMENT OF MATERIAL.
p©U-k - !UN 01 202? -
11. DATE WELL ABANDONED
I do hereby certify that this well was abandoned in accordance wit 15A NCAC 2C,well construction standards, and
that a copy of the record has been provided to the well owner.
Signature of person abandoning the well Date—lsz ��-!
7-
WELL LOCATION: Draw a location sketch on the reverse of this sheet„ showing the direction and distance
of the well to at least two(2) nearby reference points such as roads, intersections and
streams. Identify roads with State Highway road identification numbers.
Submit on Division of Water Quality, Groundwater Section, one copy to the owner within 30 days
e ion from compl of abandonment.
GW—30 Revised 12/99
JAN 0 3 2022 JLS 10/18/04 Final
NC DEQ/DWR
Central Office

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