Rowan_Well Abandonment_20230213

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, i . WELL• 'ABANDONMENT RECORD f .C ' ',' .'rr
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4 °� .+ �:. North Carolina of Environment and Natural Resources-Division of Water'Quality F-�
a . ,.� Department2023
".”' : b WELL CONTRACTOR CERTIFICATION# k2.3 7,?,
Intti,wna inn Provwg•ing Una
6. WELL DETAILS: ❑(''^Q% OG
1.WELL CONTRACTOR: i
/ 6 c d Ada a V f a.Total Depth -7 7 fL Diameter. 2,-5 In.
Well C actor(Individual)Name 1 • b.Water Level(Below Measuring Point): o2 ft.
O LJ�t H Q /1 •t Measuring point is 1 ft.above land surface.
Well Contractor Company Name`. /�� / •�
�r/(� �hQ,j,,'//� �U/,,/ �r) 6: CASING: ; Length Diameter
Street ddress
/ P C�//'7 a Casing Depth(if known): ' V e ft. in.
S�J�i'C�.U,�7 /t'� od b.Casing Removed: i G ft. in.
City brTown/ q State Zip Code
A re alb 403�e -2g 7/ 7. DISINFECTION: D 2'
Area code Phone number '
(Amount of 65%7570 calcium hypochlorite used)
2:WELL INFORMATION: 8. .SEALING MATERIAL: ,
SITE WELL ID# (if applicable)
, Neat Cement • Sand Cement
STATE WELL PERMIT# (if applicable) Cement lb. • Cement lb.
COUNTY WELL PERMIT #(if applicable) 38 f)�2 I Water gala' Water gal.
Bentonite, i',
DWQ or OTHER PERMIT#(if applicable) . �"' (IA
8S lb.
WELL USE(Check applicable use). Monitoring 15 Residential Type:0 Slurry [ ellet�I
❑ M unicipallPublic 0 Industrial/Commercial 0 Agricultural Water ' ' Igal.
1
❑ Recovery ❑ Injection 0 Irrigation Other
❑Other(list use) Type material /
Amount
3.WELL LO ION:
COUNTY CU) QUADRANGLE NAME .
•
NEAREST TOWN: .S?/'s i U plu MP
,j p
9. EXPLAIN METHOD OF ELACEMENTOF MATERIAL:
(5treetlRoad Name,Number,Cog—enmity,Subdivision,Lot No.,Parcel,Zip Code) I 1
TOPOGRAPHC/LAND ETTING:
❑Slope ❑Valley Flat 0 Ridge❑Other v
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of th®eil on the back of this
• 1�/ form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 363
-5'``— "DM5 OR 3X.)000X00X70D , in the well,gravel interval,intervals of casing perforations,and depths and
types of fill materialsised
LONGITUDE 75�Q"�I ' if "DIMS OR 7X.XX)()OOt)OC�D
Latitude/longitude source: DGPS OTopographic map 11. DATE WELL ABANDONED /d �-3
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) I DO HEREBY CERTIFY THAT THISIWELL 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 PDVIDED TO THE WELL OWNER.
(If a residential wet,skip 4a;complete 4b,well owner information only.)
FAC(UTY ID#(if applicable) Ve'9,-, /- / b - -2 3
NAME OF FACILITY SI REOFC F D LCONTRACTOR DATE
STREET ADDRESS ,
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wpersonaltyabandons hisltier residential well
in accordance with 15A NCAC 2C.6113.)
4b.CONTACT PERSONIWELL OWNER: d�/ 4,d f
NAME is a f(t h ,et MI&,f 4 PRINTED NAME OF PERSON ABANDONING THE WELL .
STREET ADDRESS )k O Q V q \1 ) R k
a, ISbL-k-_ nG
Submit a`copy AO the owner and tfle:original;toC Division..of Water Quality:-Information Processing;` Form GW-30
:1617 Mail Service.Center,Raleigh,NC 27699=1617,Phone (919)807=6300 1 Rev.5110