Onslow_Well Abandonment_20230602

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's" ,= ' "s WELL ABANDONMENT RECORD
. . Q, 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:
DLL u s\cl L ° R I %r a.Total Depth: l6. 5 ft. Diameter: 1 in.
We Contractor(Individual)Name b.Water Level(Below Measuring Point): 7ft.
�r 4 Measuring point is ft.above land surface.
Well Conwactor Company Name r
STREET ADDRESS 72-1 ° f h t�''atyy a a 6. CASING: Length Diameter
� IMP /e�C_ 2_Q I a.Casing Depth(if known): ft. 1 l�} in.
I��
City or Town State Zip Code b.Casing Removed: ft. in.
(CM) )- 29y -317S /�,�-
Area code-Phone number rl+ 1 7. DISINFECTION: 4 1 or.
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) • 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable) WattCementer gal. Water lb.
Wa gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): (nitoring 0 Residential Bentonite /0 lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry Kif llets
•
❑Recove •
Water gal.
ry ❑ Injection ❑ Irrigation
•
Other 7:
T L. ,--. . %__.5`''. 4 T is-z,'
0 Other(list use)
Type material J U N 2 2023
3.WELL LOCATION:
/ Amount
COUNTY Oi)cI CL) QUADRANGLE NAME ln;;-- „ -.-.t ". . ui-:i
NEAREST TOWN: ar<K.TO H Ul°Ole 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
•
rdurmd i+� 41 e.-I I u x-t-i I -F u
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETXING:
❑Slope 0 Valley 11d 1'laatt 0 Ridge❑Other
• I .
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE 3o May be in degrees, form showing
!�Z��3 5 minutes,seconds,or in a total depth,depth and diameter of screens(if any)remaining
Y,o / decimal format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE ? 6 1 types of fill materials used.
Latitude/longitude source: PS 0 Topographic map V
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED 5'o"'23
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) 9a.tid- if + S-9-2-3
NAME OF FACILITY SIGNATURE OF CERTIFIED W L CONTRACTOR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: 1 Cop
in ace ante with 15A NC/,�t�C 2C.0 13.)
NAME M ei Af®r'1'1i S�il.-j-e- Wa.TC t! W. ,v ,F '
PRINTED NAME OF PERSON AB DONING THE WELL
STREET ADDRESS 1+2.I diel /OL!!N 37-.
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 276 9 9-1 61 7, Phone No.[phone]'ext 568. Rev.5/06

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?--€k, 9 WELL ABANDONMENT RECORD
\�' ,, 1 North Carolina Department of Environment and Natural Resources-Division of Water Quality
""='' WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR:(( I° B. WELL DETAILS:
duel V t'eI L. 1�, 6-4-e f a.Total Depth: '6 ft. Diameter: 1 r�{- in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 17 ft.
i1, e1 1 Co
R.e 1 Ir Measuring point is / ft.above land surface.
Well C�actor Company Name," '
STREET ADDRESS 72.1 vi/e dtta e`l,"1y id 4 6. CASING: Length Diameter
Ro.re 14 JI lit Cr Zit -el I
a.Casing Depth(if known): f. 1 rs+ in.
City or Town State Zip Code b.Casing Removed: ft. in.
( 7J1) )- 2z9—3 17.6" -
Area code-Phone number 7. DISINFECTION:)411+ I AZ-.
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) - 8. SEALING MATERIAL: •
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable)e)� Bentonite
WELL USE(Check applicable use): 1. ic1 uitoring ❑Residential Bentonite /0 lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry ets
Water gal. •.--. ,
❑ Recovery 0 Injection 0 Irrigation r ¢ �..,(,
Other ,:..-4..r f'W.: -S .__.1....
. ❑Other(list use) II '' /.
Type material J V IN U 2 2023
3.WELL LOCATION: �, �;�., -;}! : I
Amount kt, +
COUNTY at o-lew QUADRANGLE NAME
NEAREST TOWN: 3q L owl dill r 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
pouvee t:1 .,6te11 "4-;1 +0 11
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING: •
❑Slope 0 Valley gat 0 Ridge❑Other •
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
May be in degrees,
LATITUDE 2.tea y minutes,seconds,or in a form showing total depth,depth and diameter of screens(if any)remaining
9 decimal foment in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 7. L10 !
�� types of fill materials used.
Latitude/longitude source: PS 0 Topographic map C e
(Location of well must be shown on a USGS topo map and i 11. DATE WELL ABANDONED J 8 -2-3
attached to this form if not using GPS.)
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) - 4etta t 3
NAME OF FACILITY SIGNATURE OF CERTIFIED W LACTOR — DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL-A OWNER: in accordance with 15A NCAC 2C.0113.)
NAME 0 id -Ala I-I .54.cd- Lthei-et CO. Oave44, L. 4?..e 1, (' .
Mora a .' PRINTED NAME OF PERSO BANDONING THE WELL
STREET ADDRESS 4Z1 Ohl
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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:'6 i a',: N WELL ABANDONMENT RECORD
;�'_ - 'a .' North Carolina Department of Environment and Natural Resources-Division of Water Quality
- WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 6. WELL DETAILS: '
DDell/1♦ L. R !Irk P a.Total Depth: ZV, ft. Diameter: 14 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): /(, ft.
ke i r Weil ll Co . Measuring point is 1 ft.above land surface.
Well Contractor Company Name
STREET ADDRESS 7 2_ I N r C W C• Chao-11 6. CASING: Length Diameter
IO.-C. 0-V11 11 719dy • a.Casing Depth(if]mown): ft. /PI in.
City or Town State Zip Code b.Casing Removed: ft. in.
( 910 )- 249--')7
Area code-Phone number 7. DISINFECTION: I-} 1 D Z•
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable)
Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): Eke<toring ❑Residential Bentonite I Z lb.
❑ MunicipaUPubiic ❑ Industrial/Commercial ❑Agricultural: Type:❑Slung [I.Ptrllets
Water gal. ? rrW
❑Recovery 0 Injection ❑ Irrigation • e; ,
Other
0 Other(list use)
Type material U 2023
3.WELL LOCATION: Amount `' C.'``"'x3 1-"'i
,..IG
COUNTY 0 n.rl011I QUADRANGLE NAME "
NEAREST TOWN: pk_r-Q it.V a`II ie9. EXPLAIN v�E THOD OF EMPLACEMENT OF MATERIAL:
poured t o Vie I( u K4-j 1 + 01
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley lat 0 Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE 3'• 8L0 33 ' May be in degrees, form showing total depth,depth and diameter of screens(if any)remaining
minutes,seconds,or in a in the well,gravel interval,intervals of casingperforations,and depths and
LONGITUDE 17'Li'0___l(e decimal format p
•
r types of fill materials used.
Latitude/longitude source: PS 0 Topographic map 11. DATE WELL ABANDONED 5�g -2-3(Location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(Ifs residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
NAME OF FACILITY �1/gA/ttit 9 2 3
SIGNATURE OF CERTIFIED W LL CONTRACTOR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: /� in accordanceor with 15A NCAC 2C.0113.) -
NAME OMWitora Q'-e BWWQ#r L.4 V 1e L. K ,.)o Tet
STREET ADDRESS LIZA Oid TO WA. S4-. PRINTED NAME OF PERSON AMNDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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�? _�`; WELL ABANDONMENT RECORD
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_;" North Carolina Department of Environment and Natural Resources-Division of Water Quality
74 ""°' WELL CONTRACTOR CERTIFICATION# I '
1.WELL CONTRACTOR: 1 6. WELL DETAILS: I i 1
-({• in.
®l,/tl �,, 'Q51 J—•�-t•( a.Total Depth: 2.-6 ft. Diameter: /
Well Contractor(Individual)Nattie b.Water Level(Below Measuring Point): Ib•j ft.
Re i -4 r We. �+I l Measuring point is / ft.above land surface.
Well Contractor Company 7Name ,- / Chats",
/ 1
STREET ADDRESS 72�1r/�wr Chas",Vy J. 6. CASING: Length Diameter
Re .e. l`'i'1 I 1 1 Y C_ ZgTJ 03 a.Casing Depth(if known): ft. /'4 in.
City or Town State Zip Code b.Casing Removed: ft. in.
("910)- Uri- 3)75 •
Area code-Phone number 7. DISINFECTION: /0 T14 )®?•
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) • 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER R PERMIT#(if applicable)li��� Bentonite
WELL USE(Check applicable use): Ly'Monitoring ❑ Residential' Bentonite , /Z lb.
❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural Type:0 Slurry ets '^. - a f"''"'
Water gal.
a.,U
0 Recovery ❑ Injection ❑ Irrigation !�, r,
Other JUN 1/ 9 2023
❑Other(list use)
Type material :n ..c ^D Pf^!':i2 A!F.Q lJrl
DWQ.780.CI
3.WELL LOCATION: Amount
COUNTY Oh.tloW QUADRANGLE NAME '
NEAREST TOWN: .Tp C.k.1'O N V 1 11 ,: 9. EXPLAIN METHOD OF EMPLACEMENT OF MATE L:
D011Ptti iA tNe)) U► 1 I 'ft)
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) T
TOPOGRAPHIC/LAND SETTING: •
-
❑Slope ❑Valley Nifra-r ❑Ridge❑Other
(Check appropriate setting) •
' 10. .WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
�I /L May be in degrees, form showingtotal depth,depth and diameter of screens(if any)remaining
LATITUDE ' O Z t1 y' minutes,seconds,or in a p p
44y'T�2 decimal format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 7 7. Tx+T types of fill materials used.
Latitude/longitude source: (_y�GPS 0 Topographic map
—g_ 2-3(Location of well must be shown on a USGS topo Wrap and I I. :DATE WELL ABANDONED !�
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) J
NAME OF FACILITY NATURE DATE
SI NATURE OF CERTIFIED t. WEL CONTRACTOR DATE
STREET ADDRESS •
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL/ _ �C OWNER:J_ f ' Coin accordance w' 15A NCAC 2C.0113.)
NAME Old kdlnb S1/r mod.+e'r Oa u ICI L. {?e3I:4-er
STREET ADDRESS 9-2I D Sd )OWN At•
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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`:4 A - "s WELL ABANDONMENT RECORD
l.- ,'�' North Carolina Department of Environment and Natural Resources-Division of Water Quality
— WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: f� 5. WELL DETAILS:
Oat.)i L, ReA 64e t a.Total Depth: /2 ft. Diameter: /hi, in.
Well Contractor(Individual)Name „J b.Water Level(Below Measuring Point): (O ft
Reel tt (` Wei I Cip. Measuring point is / ft above land surface.
Well Contractor Company Name /
STREET ADDRESS 72) t_Jeti �- (luxe it iy
6. CASING: Length Diameter
R ' 17I 1 t 14.C, a.Casing Depth(if known): ft. •
�wit in.
City or Town State Zip Code b.Casing Removed: ft. in.
(91O )- 2Sq-3175' ��,�
Area code-Phone number 7. DISINFECTION: 102.
I
2.WELL INFORMATION: • (Amount of 65%-75%calcium hypochlorite used) •
•
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Cnnd Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): lill<itoring 0 Residential Bentonite a lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:❑Slurry
❑ Recovery ❑ Injection 0 Irrigation Water gal. �- ,.,: ";.1 -. ;
Other
❑Other(list use) i r
• Type material Jv N ii 9 2023
3.WELL LOCATION: Amount In'c"''•°'c'1 p'-':-a•.Z.;?`7 flit
COUNTY 04.34OA QUADRANGLEA NAME "`'"' J
NEAREST TOWN: c�/At�c.S'O tI 0t III I'e 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
pot;1ed ,.'n t0 well tiln+i) +u\\
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley [-Aral ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE 31-•S21 7.4 Maybe in degrees,minutes,seconds,or in a form showing total depth,depth and diameter of screens(if any)remaining
--
LONGITUDE 7• �' tQZ decimal format • in the well,gravel interval,intervals of casing perforations,and depths and
types of fill materials used.
Latitude/longitude source: ❑Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED e....23
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITYMEOFID#(i applicable) _ n X,
NAME OF FACILITY SIGNATURE OOF/CERTIFIED WE CONTRACTOR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: / in accordance with 15A NCAC 2C.0113.)
N
NAME OI c NMPi' / Weeter Co. Dot Vt l� L. ke i 1t.4-f f
STREET ADDRESS `}'2 4 Ol ti 7D t.t1A At. PRINTED NAME OF PERSON Agp(PIDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. ' 1 Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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-4�` T•-, WELL ABANDONMENT RECORD
rj;( C ,g/ North Carolina Department of Environment and Natural Resources-Division of Water Quality
"'"��. WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
A 01 L. 4 I ri-e i a.Total Depth: 1-5. ft. Diameter: / ' in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): /3 ft.
Req&I—kr, Wei I Co, Measuring point is / ft.above land surface.
Well Contractor Company Name 1 �+
STREET ADDRESS 77 7 W 1 an r 1`.1-y PI .6., CASING: Length Diameter
Rese Nil I I`ve 21�eSp ' ' a.Casing Depth(if known): ft. 1 Afel. in.
City or Town State Zip Code b.Casing Removed: ft. in.
( 114 )- z -2)75' , PtT
Area code-Phone number 7. DISINFECTION: 1 V Z.. 1
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) '8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable) Cementater lb. Cement lb.
gal. Water gal.
W
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): onitoring 0 Residential Bentonite 9 lb. -- t:;_ i
❑ Municipal/Public ElIndustrial/Commercial El Agricultural Type:0 Slurry ([PetieIs ` ``.- -' t=' `..^ ' jl
o Recove Water gal. JUN N r, 2 2023
ry ❑ Injection ❑ Irrigation J IV V U
Other
['Other(list use) : a ?f.r;^.,,, ,7 1.1r;
thy.,-ri�`:':
Type material D 'Q.r u'.'{r
3.WELL LOCATION: _ Amount
COUNTY Con,fhp 1.0 QUADRANGLE NAME
NEAREST TOWN: 01 G<G ks p it V,IJ I Y 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
pOVVed �n (;yell v h4-0 -cv 1 k
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley •at 0 Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
A May be in degrees, form showingtotal depth, any)remaining
LATITUDE •/��3�9 __ depth and diameter of screens(if
-minutes,seconds,or in a
in the well,
decimal format gravel interval,intervals of casing perforations,and depths and
LONGITUDE ?7. 4'o6Zyle types of fill materials used.
Latitude/longitude source: P5 0 Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED 5."S'-2
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH I5A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner infomiation only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(ifapplicable) Sim hi vn , '
- � 1 S—-1 Q-7-,NAME OF FACILITY
SIGNATURE OF CERTIFIED WE CONTRACTOR DATE
• STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance V with` 15A NCAC 2C.0113.)
NAME 19/d /Vd h k ,-l ' -t Co. 1 or�O 1 / 1.--• PeCilb-del'
PRINTED NAME OF PERSON AB DONING THE WELL
STREET ADDRESS Z4,2.1 did Ti tdt%
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. I I Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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