Alexander_Well Abandonment_20220909

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WELL ABANDONMENT RECORD -.
North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth 35 ft. Diameter.24 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 32 ft.
Measuring point is 0 ft.above land surface.
Well Contractor Company Name
6. CASING: Length Diameter
Street Address
a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: �3 ft. 24 in.
Are a Phone number 7 DISINF�ECTIIOON
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION:
8. SEALING MATERIAL:
SITE WELL ID_# (if applicable)
xc Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. _ Water oal.
Bentonite
DWQ or OTHER PERMIT #(if applicable) RECEIVED
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WELL USE (Check applicable use)S Monitoring 0 Residential : Bentonite lb. SFP Q 9 2022
Type:❑ Slurry ❑Pellets
❑ Municipal./Public ❑ Ind ustrial/Commercial ❑ Agricultural Water gal. Ir4DffA&60n Arm
❑ Recovery ❑ Injection ❑ Irrigation Other CAMBOG
❑ Omer(list use) Type material day soil up to the top of the casing
3.WELL LOCATION: : _Am0unt1� � 1c'�
COUNTY Alexander QUADRANGLE NAMEN�flv�,
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NEAREST TOWN: Taylofsville 9. EXPLAIN METHOD OF EMPLACEMENT OF MATtRIAt
i
! 61;d plaeed the well
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
VP Slope ❑Valley ❑ Flat ❑ Ridge❑ Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 35 o 55 5.0000 "DMS OR DID in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 81 11 49.0000 DMS OR DD types of fill materialsised
Latitudeflongitude source: 03PS pTopographic map
(location of well must be shown on a USGS topo map andattached to 11,D`ATEtWELL ABANDONED Qd15'e
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a; : THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable)
NAME OF FACILITY SIGNATU RTIF LL CON CTOR DATE
STREET ADDRESS * L L.
: S_i7G R TOF�E DOWNER ABANDONING THEW tL DATE
v f he n"'"aie�ell caner must been°ndivid al w rsonall""ba dons hisJhecresidentiaY ell
City or Town State Zip Code (T P� �
�n�withlSANC
4b.CONTACT PERSON/WELL OWNER:
Stone Smith ,� _.
NAME PRINTED NAME'OF:P_E_RSON BANDONIIVG
STREET ADDRESS 305 Polk Street
Submit a copy to the owner and the original to. Division of Water Quality- Information Processing, Form GW-30
1617 Mail Service Center, Raleigh,NC 27699-1617,Phone:[phone] Rev.5/10
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