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Home My WebLink AboutIredell_Well Abandonment_20221205 _ l' i s WE . •ABANDONMEI�jT R—r'_. __COR North Carolina Department of Environment and Nahtral Re umm-Division of*a Quality WELL CONTRACTOR CERTIFICATION# Ci)- 'Z � — A- d ? 1.WELL CONTRACTOR. �Q- L()40 ' 5. WELL DETAILS:aTotalDepth V .�:tt. Diameter. In. _ W1.►C iJ�A Well Contra ndividuai)N rr a b.Water Level(Below Measil"Polnt): JI. v �NkC-,IA l S �L�n Measudng pint Isr ft.above land surface. I o or Company Nama S tAdd E 1-' S. CASING: C� I Length _Diameter oGt 5 ' a.Casing Depth(rf tmown): 2� R. in. Y or Tom ( State Zip Code b:Casing Removed: }l In. wit l(_3 S �` �t Area code Phoner"� 7. DISINFECTION• 2.WELL INFORMATION: (Amount-,f 65% cal tun hypoehtorite used)'" 'SITE WELL iDP.(ffe cable) � 8.• SEALING MATERIAL- , SPATE WELL PERMIT#'(if al' e) 98lid.!�4IDOD1 �p Cement—lb.: Cemen(,;_____`Ib. CO(1NTY WELL PERMIT [if(if eppllcablehO� ►��Z—Q9' Water gaL Water aal. DWQ or OTHER PERMIT; (iF applicable) gltonito WELL USE-(Checkapplicableuse)0 Monitoring Q Rosldentlal Sentanite, bj ' ElMunicipallPublie n6'f dustrtaUConunerctal ❑`Agricultural Type:0 ❑Pe Water gal. ❑ Recovery ❑ Injection p Irdgatlon caller 0011her(Ust use) Type material . I��y€` d IWELL LbC N: Amount — COUNTY � -/sQ�U.A.lDRRAANNGIENAMEI— Z�ZZ NEARESTTOWN: �/i �s r✓/��[ L EXPLAIN METHOD OF EMPLACEMEUTdi MA'f@IgiLpj.l_--='>::-"n-I Un �+ J (StreetiRoad Name,Number,Community,Subcnvls areal,4 Code) -TOPOGRAPHC/ ❑Slope ❑ at ❑Rldge❑Oft r I' edc apprCpdate setting) 10. L DIAGRAM :Draws detailed sketch of tteell on the back of this J� to shpwing total depth,depth and diameter of screens(if any)remaining IJ171TUDE 38 Dt1A5 OR 3X.xXIOOat)til)pD in a well,gravel Interval,intervals of casing perforations,and depths and LONGITUDE7��o I ORTX.XXKXKX =D of flumatsrtomw Lattt mongitude s0wro : S Oropographie map (fooathn ofweBmestbe akown on a USGS fopo�mep anttac 11. DATE WELLABANDONED' l� • truatffrrotusirra�P I 100 HEREBYCERMFY THATTHIS WELL WAS ABANDONED iN ACCORDANCE WITH ISA NCAC 1%WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF 46.FACiLfTY-The rteine of the huainese where the wag le located.Complete 4a THIS REC HAS B PIbVI ED 70 77 L CKa r®iden W wdL,ship 4M Complete 4b,well owner Inform_atio_n only.) FACILITY ID ale(if applicable ' r NAME OF FACILITY` ! '/frsS ' : al OF CERIVIED WEL ONTRA R DATE SiR RESS' � r� y��l t SIGNATURE OF PRIVATE WELL OWNER ABANDONING TIME WELL DATE . CftycrTown State Zip Code (The Private well ownermwtbeanf� rralw onohblherreeldeMlelwell 4b.CONTACT P7/cm MWELLOWNER: :`Ueecopdaneew / NAME. — i'J� : yP,RiNTED NAME OF PERSON ABANDONING THE WE LL STREETADDRESS .A Sutiniit a copy to the owner and-the original llo.DJVlslon-of.Water Quality-infornintion Pro' cesBing, Foy Gw ao 1617 real)Service Center,Raleigh,NC 27M-1617,Phone:(919).607e6300 I Rev. G �,. _ . 00 I �� p �� / �" � . . . �� G .� ��. �.. . �.�p � _ . �� __ _ C� �� /,� �� . � .S� �� - � � .� �� dog , RECAM t Y c North Carolina Department of Environment and Natural.Resources-Division of Water Quality WELL CONTRACTOR CERTIFICATION# 1fV CIJ' 3�—�, - 1.WELL CONTRACTOR: ; a WELL DETAILS: i I , '` _�lI� 1 1` 1 _ ,` �� GnQGl,il O7 C_�M! a aTotal Depth ft. Diameter. in. Well Contra . �lndividuai)N ` e^.a`1 1 b.Water Level(Below Meal ng Point): ft. Measuring pointle - it.above landsurtace. 1 h or Company Name t , 1 i N W_DL'2 V�Q,�� i kA(t, L Vet S. CASING: Lergp Diameter ___ a.casing Depth(If known).' il. In. CIV or oow�n(��l _ Mete Z1p Code . b.'Castng Removed: ft in. t..li�1_)—S I r 7. DISINFECTION: LlG .�4�t ✓Area code' Phone number 2.WELL INFORMATION: (AmouhLof 85%75%calduin hypochtorite used) SITE WELL tD#•(if applicable) �— 8.• SEALING MATERIAL; ,.• STATE1tYELLPt7tM1T# (ifapplIg NUMBmeSt Itble) /� ' 2' Cement lb: ement<__.___`lb. COUNTY WELL PERMIT #(if epplieablekXbj tom' 6Z'L'te&W; Water r at DWQ or OTHER PERMIT-#(ilapplicable) a �� WELL USE(Check applicable MonRoNng ❑ Residential F ent ro' 0 M unrd Type:❑Siury peiiPubitc IndtlathaUCommarclal ❑=Agricultural Water ❑ Reeovwy ❑ injection ❑ Irrigation :b OfhBf 0 Other(ffst use) Type material ti:WELL Lop"q Amounti_ � -.COUNTY QUADRAN NAME �J NEAREST TOWN �Srl //t/ 9. EXP METHOD OF EMPLACEMENT OMATF�tUtL r (SlreetdRond Name,Number.Community,Subdivision,Lot No.,Paml,Zrp Code) :TOPOGRAPHC/LAN NG: .❑Slope ❑ allay ge .v . Other Che roprla�tese/ttiJnjg)) 41 Q 10. WELL DIAGRAM :Draw a detailed sketch of tholl on the back of this DE 3 _ i /ter/l�U� form showing total depth;depth and diameter of screens(d arty)remaining DMS OR jX.X=00d(ftD in the well,gravel interval,intervals ofeasin lONt31TUDE 7 p MS OR 7X. g perforations,and depths and XXXXXXX 1pD types offill matsdlilhu l 1 atittldeAoMitude souroer S pi'opographie »ofxrel/mrisYbe map andatfached to 11. DATE WELLABANDONEt) this i 100 HEREBY CERTIFY THAT.THIS WELL WASABANOONED INACCORDANCE 4a.FACILITY-The mane oft VNTH 15A NCAC 2LL CONSTR1JC710N STD AN THAT A COPY OF he hushiess where the wen Is located.Complete 4a r : THIS RECORD S PN FD THE O EFT. (If a rraldental well,skip 48 compiete 4b,well owner IMomwon oNy y FaautY w 01'appucal>1e NAME OF FACiLIT.Y : SIGNA CERi1Fl WEIt CO R DAne STREET RESS �/fA /?, a (� B. _ - 81GNA RE OF PRIVATE WELL OWNER ABANDONING WEW DAT ELL E City or own State • tip ode (nm PdvBtD well owner must be an fndlvlduel wlMapdhpbandon®hb/her residential wen 4b CONTACTP SONWELLOWNER: In:accord�paewtih 16ANCA�A2 113) � NAME. ' /ICJ -_ .i. /i NO PRINTED NAME OF PERSON AiANDONING THE VJE LL STREETADDRESS Submit a copy to the.owner and,the original to:Djvlslon-of Water Quality-Information Procassing, Form GW-30 1617.Nal1 Servlce Center,Raleigh,NC 27699-1. 617;P*Ip:(919)$074300 I Rev.Min 5 1