WQ0004268_Well Abandonment_20180618

WELL ' ; ANDONMENT RECORD
North Carolina Departrrient of 1 nvirontnent and Natural ltesourceS- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2 3 /.. '- A
1. WELL CONTRACTOR:
a
Wc8 Contmctor (Individual) Natne
w' b L C.6•
Wall Contra or Company Name
S1'1t Ef ADD.RESB 72- ids) • C t i '4-y RJ
2 7L4 9
City orTownl State Zip Code
,..Z1y — 3) 7�
Area code- Phone number
2. WELL INFORMATION:
SITE WELL fir ii (if applicable) RAN
(
STATE WELL PERMVMTT N (if applicable)
COUNTY WELL PERMIT N (if applicable)
;aF Oi:0eibI11ER•YEitii1iiT t(lfapp4cublej: 0424$
WELL USE (Cheek applicable use): • ' + oniteriag 0 Residential
0 MunicipiWl'ublic 0 Industrial/Commercial Cl Agricultural
© Recovery 0 Injcetion 0 'Mention
❑ Other (list use)
3. WELL LOCATION: •
COUNTY,"S. t ny'>,pb 14 QUADRANGLE NAME T
NEAREST TOWN: rVY=I-Qt
oR1,2ER_ A Lt.-ea CaAmitx, - 5/4
(Stree4110-dd Name, Number, Community, Subdivision. Lot No., Parcel, Zi
TOPOO RAPFI IC / LAND SETTING: 1 r, id.iDO 1
❑Slope ❑Valley •lit ❑Ridge0.0ther '+°
(Check appropriate,
props te, setting) 3 6
A0 -
LATITUDE 3l 57 400,
LONGITUDE 78'° (2 5:7
78 ),Sg7
Latitude ungitudesouree:
Maybe in de_^ees,
minutes, se,Vgds, or in n
decimal format
PS ❑Topographic map
(Location of well must be shown an a USGS topo map and
attached to thisforr if not rasing GPS.)
4a. FACILITY- 'the name orate bwvws, wheree fhb well is located Complete 4a and4b.
(If a residential well. slip 4a;complete 4h, well ovmaSnformatiaaong:)
rACILITYID!I(irapplicable) ?ert...4.3 14.)4ro0 A/24a
NAME OF FACILITY G-1 it t e 9' ♦„a • . _
STREET ADDRESS Sq on. Mrr1ti1. V
City or Town 1 Staattv'� Z ip Cccle______
4h. CONTACT PERSONIWELL OWNER:
NA11E _ �51ti..-.1-}.its id Ycood$
STREET ADDRESS ,.2 gf.A % y.7 l k)4 �%ar34r.✓
A)4. ?2531$ J
6. WELL DETAILS: '
a: Total Depth: 30 ft Diameter: 2-- in.
b. Water Level (Below Measuring Point): . g R
Measuring point is 2.-. it. above land surface.
6. CASING: Length Diamatu
a. Casing Depth (if larown): R . in.
.........3.6
b: Casing Removed: 36 iL in.
__,,.__._
7. DI.SINFECfION: J 04.
.
(Amount of 65% 75% calcium hypochiorite used)
& SEALING MATERIAL:
Neat ('wneur Rand' foment
Cement -lb. Cement. Ib.
Water gat. . Water... gal
d
Bentonite
Bentonite � lb. DEAD � "r R -
. Type: 0Slutry 1141<drs Q r 1 0
Water gat. . L 11 i d
eher. .
ROS
Type material FAYE'rT-EV!LLFQ
�"��_,�� ( ,�ti C
Amount
R?, v °T, 7
EXPLAIN METHOD OF EMPLACL?MEN•'1' OF MATERIAL:
1-701$ Pew reti. 40will kDLA U.ii,T1 1
i4- 03exe• *U}l \r
10. WE LI. DIAGRAM:.Draw a detailed sketch of the well on the back of this
form ahowiug total depth, depth and diameter of screens (if any) rernaining
in die wall, d avel.interval, intervals of casineperforntions, and depths and
types of fill materials used. _— + q
11. DATE WELL ABANDONED /se — �.g" 1.1i
1 DO HEREBY CERTIFY THAT THIS. WEt.I. Rh1S ABe1NbWN) iN. ACCORDANCE
WEDS ISA NCAC 2C, WELL CONS'IRU(;"l7ON S`'('ANT)AROs, AND 'MAT A COPY OF
. THIS RECORD HAS 13ED"PROVIDEDTO THE WELL OWNER.
tzurteeI' .t%�, — i
SI 'NATURE. DE.CERTIFIED WELL NTRaiCfOR DATE
•
SiGNATWIitR OF PRIVATE WELL OWNERABANTVVi 10 T1LS W!' LL DATE
(Ile private well owrter nunt be an individual Ate presently abandons hisitertetiitcatihi well
lot a(cetaince with 15A++NCAC 2C.0I13.)
4/A 1,h is �P r:5'�T. :. .. .
PRINTED NAME OPPERSON An A ON'1NOT IE•WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days.
Attn: Information Management, 1617 Mail Service Center —Raleigh, NC 27699-1617, Phone No. (9(9) 733.701S es1568.
Foot CIW 30
Rev. 5/06
FFICE

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Parcels (Yellow) °
Ct xr n
Tax Bill
Deed
PIN: 18053760005 I
OWNER: KAMCP, LLC
OWNER ADDRESS:
585 CROSS CREEKTRL
OWNER CITY: GIBSONVILLE 1
OWNER STATE: NC I
OWNER ZIP: 27249
ACREAGE: 38.71
APN: -2434 I
BK PG: 1973/704
DATE RECORDED: 4/28/2017
LAND TAX DEFERRED: 0
ASSESSED VALUE: 1613659
TOTAL TAX VALUE: 1613659
SITE ADDRESS: 5900 TURKEY HWY
TWP CODE: 18
TAX CODE: F10
SEG TYPE: COMMIRESIDENT I
CONSIDERATION: 900000
APPR SEG VALUE: $329,100I$33,540
USE DESC:
TYPICAL OFFICEIWAREHOUSE
STORAGEIWAREHOUSE
STORAGEIWAREHOUSE
STORAGEITYPICAL
OFFICEJWAREHOUSE
STORAGE!SHEDITRUCK
SCALESIWATER TANK (BY 1000)
IPUMP HOUSEIRAIL ROAD
SIDING1SHOPI6FT CHAIN LINK
FENCEIPUMP HOUSEIMETALTANK
(BY 1000)IMETAL TANK (BY 1000)
'TRUCK S
RESIDENTIAL
24340040. '
2434188788
34.601305
Revi- -.
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