Catawba_Well Abandonment_20220912

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` North Carolina Depettment of Environment and Natural Resources-Division ofI Quality
WELL CONTRACTOR CERTIFICATION#
1:WELL 6011TRACTOR. 'UI 11 6. WELLDETAILS: r.
aTotal Depth it. t)Iameter. P In.
Well _-�
Contract ndivfdusi)Ner e '' II b.Water Leval(Below Measuring Point):
Measuring point Is --R above land surface.
11 o or Company Name . 1 , 1 c �;
1�1�L21�D . ACC . L1�1 S. 'CASING: Length Diameter
$jr{38t Add
a..Casing Depth(if lawwn) 09fR. In.
Cdy or Townn _ fate Zip Code b.Casing Removed: ft _ kL
Are Ls�) �l S ' � � � 7. DISINFECTION: / /C o owl.�C�
Area Code Phone number ,
.Z.WELL INFORMATION: ;^(Arirouhtnf 85%75%calcium hypochtorite used)'
817E WELL ID#•(If epphcable)_.,:::::�__ B.• SEALING MATERIAL:
f
Si'ATE WELL PERMIT#I (if oppricabl'a) - i 4IDOD
Cement !b. Cement --_lb.
COUNTY WELL PERMIT #(If appllcable),e(ttf't/ � Cam// 1 water gaL w ---
", p o'E 'j�'+:-
DWQ or OTHER PERMIT*(if applicable)
*ELL Use(Check applicabieusep IlAonitoHrtg S eslden@al `= Beritonite Ib. SEP 1 2 2022
Type:❑SI eVets
❑ Munic#mMubtic ❑ IRdustriaUCornmerlWl ❑-Agricultural 1. 961. Inf�r��nrlcn FroccAning Unit
❑ ReeavWY ❑ injection a Irllgatlo Othe —
❑� ;QJ6CC>G
Other(list use) rialType mate
8.WELL LOC N: Amount
COUNTY+ _
NEAREST TOWN: � �� 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL
(SbestlRoad Name,Number.Community,SuMvWhm,Lot No.,par=,,Z(p Code) U
TOPOGRAPHC/LAIND S
0$tope 0.Valley Rap' t ❑Ridge[)Other
(Check appropdite setting)
10. WELL DIAGRAM :Drew a kdeteifed sketch of theell on the back of this
LATITUDE 3 � /�J °DN15 OR 3X.xlDD(tobtlDpp fomt showing total depth;depth and diameter of screens(deny)remairing
in the well,gravel Interval,intervals of easing perforatfons,and depths and
LONGITUDE 7 D_ &e"DM5 OR 7XJODt)p M0WD types oflJU materiels sw.
Latibtdeltangitude source:.MPS &0pographic map
(fochtbn of weUniustbe shown bn a USGS fopo map endeftached to 11. DATE WELL ABANDONEDthis rams ff not"sing GPS)
: 1 DO HEREI CER nFY THAT.THIS WELL W ABANDONED IN ACCORDANCE
VNTHIQANCAC2C,WELLCONSTRUCTIONSI•AMOARDS, DTHATACOPYOF 4a.FACILITY-The Dane orthe business wfiem the w8B Is located.Complete 4as : THIS RECORD HAr ED TO THE CC
(if a restdentM well,Skip 4a;Complete 4b.well G_Wjer_Information oNy.)' J �i
FACILITY ID 8(if applicable)
NAME OF FACILITY SIGNA C WELL CO R DATE
STREET ADDRESS ® �'
�� SIGNATURE OF PRIVATE YItELL OWNER ABANDONING THE WELL DATE
C Or oiNrt to p Cott (rhe Private well owner must be an indlvkluit wJWppWilpbandotro his/her reskiential wall
4b.C0@1TACT PER30 ELL OWNER: : In_acw�nee with 15A NCAC 2C.01 1;S.)'
SGT NAME. ` i 1
' PRINTED NAME OF PERSON A9At11DONINe THE WE RL.
STREErADDRES§ d 2 f ^-t 6) I,
-Submit a copy to-the owner and'thet original tq:PIVIelon'of Water Quality-Information 0tocess;ng,
1617 Mall Service Center,Raleigh,NC 27699-1817,P.hone_:(919).80743 Fenn�w 3D
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+ r_ S Y•i A AN��NNi�NT RECORD
s North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# CIJ' _ A-
1.WELL CONTRAC`TOP- 1 j S. WELL.DETAILS: f` f
I /
a.Totat Depth. _ft. Diameter.
Wall Contract9tV ndividuat) e 11,, b.Water Level(Below Measuring Point): SCe�—
f,l S -�+/� Measuring point is- fL above land sudere. (�t/�rCAl'
Il o or Company Name
lf��Qtl��a ACS L1V S. CASING: ��/t�C.� Leno �—Dfamstar
a.Casing Depth(if lomvm)- r ft.
City or Town pate Zip Code I b-Casing Removed: It ZZEft. — In.
Area code Phone number410 7. DISiNFECT10i:
2.WELL INFORMATION: (Amountof 65%75%calcium hypochkx to used)
SITE WELL.W 0•Of applicable)_ � : 8.• SEALING MATERIAL
i
STATE WELL PERMIT# (if applica — tlBbt�ameut Send- t
��/� Cement Cern
COUNTIfWELLpERINCI #(ifappicabte) t�"l� 0 WeterTZ�gal. Water aal.
Cbi G�f�/'/'� a tonne ram.�e f,
DWQ or OTHER PERMIT#(if applicable) .EE��'E I V
WELL USE(Chock appircable use)EI Monitoring kiZdandel Ben7ypet [b,
0 MUnldpalfPubite ❑ IndustriaUCommarcial ❑ dgricalturat '°Si e oat. SEP f ., ZOZZ
Wate
❑ Reeovwy ❑ In)ectlon 0 irrigation Ir�;�r�+�ak�� PrC-C wttg Unit
Other
❑Other(ustuse) Type:mateflal P W r
a:*ELL LOCATI blc� Amount7
COUNTY - OUADRANGIE NAME
NEAREST TOWN: �/f G L,K1 ; 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL-
(StrestlRoad Name,Number,CommuNry,subdviston.Lot No..Parml,z(p Code) COE; C w
• •G
TOPOGRAPHC 1 LAND SMG: Z '� cLlC 4C V J-c A
lop❑Se O Valley B F1' at ❑Ridge❑Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell an the back of this
LATITUDE 3te
�l DMS�OR, ��shWng total depth.depth and diameter of screens(if any}remaining
)Ot)OUObfX)DD in the well,gravel Interval,1;r6ryals of casing perforatio s,and depths and
lONQITUDE 7 � DMS OR'7X•)o0009!j=--D types of flu materials,
LatAudettongitudesotme: pTopographicmap aa �
(fecatb»Ofweflinu"be shown an a USGS tapo map andaffached to 11. DATE WELL A13MDONED tJ
this km ffnotu&M GPS)
: 1 DO HEREBVCER7iFY THAT.THIS WELL W ABAN IN ACCORDANCE
WITHISANdi 2C,WELLCO UCTIO AND ANDTHATACOPYOF
4a.FACILITY-The rtarrte ofthe buslrmse where the wan 1s[Grated.Com Oar THIS REC BEEN PR ED TO WF1' ER.
(li a restdenttN well,GNP 4a:Complete 4b.reiiryjrinfamq FACILITY ID 0(if applicable) • - /�,
NAME OF FACILITY : SiG OF ED WELL NTitACTOR DATE
EETADDRESS
dYGrr/ . SIGNATURE OF PRIVATE WLL E OWNERRAgAAriDOLI1NG THE WELL DATE
CitycrTovm State Zip Code CftprivateweU owner muct bean IndM'dualwJIK5gW bamlonQtkWherresiderftwoo
4b.CONTACT PERSONIWELL WNER: Inaeconlaneewi0r16ANCAC2C.etfj.)
NAME. C !
PRiNr6D NAME OF PERSON ABANDONING THE WE LL
STREETADDRESS ZCY7, 1LL0„0,y4-5 C '
Submit a Copy to the owner and-the original Ii19s©wision'of Water Quality-Information PFocessing,
1617 Mall Service Center,Raleigh,NC 27M.1617,;Pltone:(919).8p74300 Form GW-30
Rev.W t0
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