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Home My WebLink AboutWQ0004268_Well Abandonment_20091210WELL ABANDONMENT RECORD North Carolina Department of Environment and Natural Resources- Division oI' Water Quality WELL CONTRACTOR CERTIFICATION #2527 1. WELL CONTRACTOR: David E. Meyer Well Contractor (Individual) Natne Protocol Sampling Service, Inc. Well Contractor Company Name s'rREE'rADDRESS PO Box 31133 Raleigh NC 27622 City or Town , State Zip Code (919 ) _ 210-6547 Arca code - Phone number 2. WELL INFORMATION: SITE WELL ID # (if applicable) water supply well STATE WELL PERMIT # (if applicable) na COUNTY WE:I.1. PERMIT (if applicable) na DWQ or OTHER PERMIT # (if applicable) na WELL USE (Check applicable use): ® Monitoring ❑ Residential ❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ Irrigation ❑ Other (list use) 3. WELL LOCATION: COUNTYSampson QUADRANGLE NAME NEAREST TOWN: Turkey 5900 Turkey Highway Turkey NC 28393 (Street/Road Name. Nwnber. Community, Subdivision. Lot No., Parcel. Zip (7ode) TOPOGRAPHIC / LAND SETTING: ❑Slope ❑ Valley © Flat ❑ Ridge ❑ Other (Check appropriate setting) !Arm lD); 34 58' 23.94' LONGrruDE 78 14' 32.31" May be in degrees. minutes. seconds. or 1n it decimal format Latitude/longitude source: © CPS ❑'1 opographic map (Location of well must he shown on a (:SGS top, map and wtached to this form if not using GPS) 4a. FACILITY- The name of the business where the well is located. Complete 4a and4b. (Ifa residential well. skip 4a: complete 4b. well owner information only.) FACILITY ID #(irapplicable) NAME OF FACILITY Allen Canning s'TRE EFADDRESS 5900 Turkey Highway Turkey NC 28393' City or Town State Zip Code 4b. CONTACT PERSON/WELL OWNER: NAME Mr. Tommy Langston STREET ADDRESS same as above WELL DETAILS: a 'Total Depth:122_0, _— Il. Diameter. 1.25 b. Water Level (Below Measuring Point)' 2' Measuring point is 2.0' _ It. above land surlace . CASING: a Casing Depth (Ifknotvn) h Casing Removed DISINFECTION: na Length Diameter 7.0' II 1.25 ,n 3.0 (Amount of 65%75% calcium hypochiorite used) SEALING MATERIAL: Neat Cement Cement 24 __ _ Ib. Water 3 gal Bentonite Bentonite Ih Type: ❑ Slurry ❑Pellets Water gal Other Type material Amount Sand Cement Cement lb Water_ EXPLAIN METHOD OF EMPLACEMENT OF MA'1'ERim.: Complete -well head and top 2 feet of well pulled -.- from ground. Well filled with neat cement grout to surface. Covered with topsoil. 10. IVEI.I. DIAGRAM • Draw a detailed sketch ol'the well on the back of this form showtng total depth. depth and thanteler of screens t 11 um ) remaining In the well. gravel nner%al. interx ik of casing perforations and depths and tlpes of till matenals used I I. DATE WELa. ABANDONED 11/30/09 I DO HEREBY CERTIFY rHA'r'I'I-IIS WEI.1.. WAS ABANDONED IN ACCORDANCE WITH ISA N('AC 2C. WELL CONSTRI,c rION STANDARDS. AND TIIAT A ('UPY 01 THIS RECORD HAS BEEN PRU\t0LD To THE mil.I. OWNER. SIGt 1ll:RF. OF CERTIFIED 11'Eq/. C:UN'I'R:1("I'OR 12/10/2009 DATE SIGN.4'ITGRE OF PRI1'A'1'E N'ELI. O\1 \ Eh •1 B•1 \ DON I\(: '1'1IF: 11 El.l. DATE ('the ornate well owner must be an null% Ideal who persvnull.) abolitions his her residenual'ell in accordance with I5A NC:\C H' 111 I. David E. Meyer PRINTED NAME OF PERSON ABANDONING: TIIE WEI.I. 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, N(' 27699-1617. Phone No. (919) 733-71115 est 568. Form GW-_U Rev 5/Oh 02! w n t r- t6M i T I.2s" si. Pser - (-7 ) (O.01fj Sul) WELL ABANDONMENT RECORD North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION #2527 I. WELL CONTRACTOR: David E. Meyer Well Contractor (Individual) Name Protocol Sampling Service, Inc. Well Contractor Company Name STREET ADDRESS .P0 Box 31133 Raleigh NC 27622 City or Town State ( 919 ) _ 210-6547 Area code - Phone number 2. WELL INFORMATION: SITE WELL ID # (if applicable) R-2 Zip Code STATE WELL PERMIT # (if applicable) na COUNTY WELL PERMIT # (if applicable) na DWQ or OTHER PERMIT # (if applicable) na WELL USE (Check applicable use): © Monitoring ❑ Residential ❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural ❑ Recovery 0 Injection 0 Irrigation ❑ Other (list use) --------.. _—_._--•- 3. WELL LOCATION: COUNTY Sampson QUADRANGLE NAME NEAREST TOWN: Turkey 5900 Turkey Highway Turkey NC 28393 (Street/Road Name. Number. Community. Subdivision, Lot No., Parcel. 'Lip Code) TOPOGRAPHIC / LAND SETTING: ❑Slope 0 Valley 21 Flat ❑ Ridge 0 Other (Check appropriate setting) LA'rrruDE 34.971024 LONGITUDE 78.234232 May be in degrees. minutes. seconds. or in a decimal format Latitude/longitude source: © CPS ['Topographic map (Location of well mug he shown on a USGS topo map and attached w this form if not using GPS ) 4a. FACILITY-'ncc name ofthe business where the well is located. Complete 4a nnd4b. (Ira residential well. skip 4a: complete 4b. well owner information only.) FACILITY I1) #(if applicable) NAME OF l:,\cll.ri v Allen Canning STREET ADDRESS 5900 Turkey Highway. Turkey NC 28393 City or Town State Zip Code 4b. CONTACT PERSON/WELL OWNER: NAME Mr. Tommy Langston STREET ADDRESS same as above 5. WEI,1. DETAILS: a Total Depth: 15 11. Diameter. 2.0' in b Water Level (Below Measuring Point) .6.55 IL Measuring point is it above land surface 6. CASING: I.ength Diameter a. Casing Depth (il'known)• 5.0' rt. 2.0' m h. Casing Removed: 5.0' It. 2.0' lit. 7. DISINFECTION: na (Amount of65%-75% calcium hvpochlorite used) 8. SEALING MATERIAL: Neat Cement Cement 47 Water 3 Bentonite Ib gal. Bentonite Ib. Type: ❑Slurry ❑Pellets Water gal. Sand Cement Cement Ib. Water — gal Other 'type material _______ -.... ._ . _ . . _ _..—.. _------ Amount 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL: Complete well pulled from ground Annulus filled with neat cement grout to surface. 10. WELL DIAGRAM Draw a detailed sketch ui the well on the hack of this firm showing total depth. depth and diameter of greens 1 n' am i renrunnlg in the well. gravel interval. intervals uleasing peri'orauons.:td depths and types of lill materials used 11. DATE WELL ABANDONED 11/30/09 I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE WITH 15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF _J:AA-P-EttYittrtI. SS BEENPJU)VIDEO'1'0THE WELL OWNER. 12/10/2009 si( fl'RE: OF CERTIFIED 1 EI:L i:iiNi RA( TOR DATE: SIGNATURE, OF PRIVATE WELL OWNER ABANDONING THE: W F,LI. DATE (The private well owner oust be an individual who personalty abandons his•her residential well in accordance with I5A NCAC 2C' .0I 13.) David E. Meyer PRINTED NAME OF PERSON ABANDONING THE. WELL. Submit a copy to the owner and the original to the Division of Water Quality within 3(1 days. Attn: Information Management, 1617 Mail Service (:enter — Raleigh. N(' 27699-1617. Phone No. 1919) 733- 71115 ext 568. Form OW-.0 I' a 5!tt(, Ft o 64-0 • —4X1,,5- :-reD- Cwg •Gm—Z1 K Z' (DaF-er PAD 7_NC,WSJ 01/4/4Nep) { � 604l N rrl F1-Vb Ooptiari CANTO (RA'EL PAGK (V-:J\('JQ') (0 C6-impJ 6o) L1.0IDe 5CRE60 (k 1c O)