Alexander_Well Abandonment_20230626

• 5AT;a
64 WELL ABANDONMENT RECORD
�c
e North Carolina Department of Environment and Natural Resources-Division of Water Quality
�• ° "'°'` WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth 160 ft. Diameter:6 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point):65 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. 6 in.
City or Town State Zip Code b.Casing Removed: ` ft. in.
( ) 7. DISINFECTION: /Z! e •-
Area code Phone number
2.WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
8. SEALING M: -IAL:
SITE WELL ID# (if applicable)
.-• •u.ait Sand Cement
STATE WELL PERMIT# (if applicable)
'ement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. Water gal.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite lb.
WELL USE (Check applicable use)❑ Monitoring 0 Residential
Type:❑ Slurry ❑Pellets
❑ M unicipal/Public ❑ Industrial/Commercial ❑ Agricultural Water gal.
❑ Recovery ❑ Injection ❑ Irrigation Other /i� ,�( //.
❑ Other(list use) Type material eiln�� yCP J5 4,/i/4/7-57 51,
3.WELL LOCATION: Amount
COUNTY Alexander QUADRANGLE NAME t' n
NEAREST TOWN: 698 Sam Poole Lane,Taylorsville, NC 28681 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) -
TOPOGRAPHC/LAND SETTING: JUN 2 .3 2U23
'Slope ❑ Valley ❑ Flat ❑ Ridge❑ Other
knt'acimwiun 1'rr.c,Dos4,..g Lnst
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detaileak—etj'tbtlt&ell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 35 49 . 27.0000 ''DM5 OR DD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 81 012 . 33.0000'DM5 OR DD types of fill materialsised
Latitude/longitude source: PhPS Qropographic map 11. DATE WELL ABANDONED 3L.W/03
(location of well must be shown on a USGS topo map andattached to
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 PRVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable)
NAME OF FACILITY StIATU E OF CERTIFIED WELL CONTRACT DATE
STREET ADDRESS t ^n►
Offal(
I N T F P7'fl
ATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The rivate well owner must be an individual wpersonally3bandons his/her residential well
!i
ac rdance with 15A N AC 2 011 .)
4b.CONTACT PERSON/WELL OWNER: � .44P
44 � /� fl .0 t( 1 rct(4
NAME Paul & Lynn Dillard PRINT NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS2167 Hidden Valley road Taylorsville,NC 28681
I
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

- 4 i __ , WELL ABANDONMENT RECORD
,:, ii ,) North Carolina Department of Environment and Natural Resources-Division of Water Quality
s .......;;1- I
" "",00 ' WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth 59 ft. Diameter:48 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): ft.
Measuring point is 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: ft. in.
—) 7. DISINFECTION: 1/2 lb.
Area code Phone number
(Amount of 65%75%calcium hypochiorite used)
2.WELL INFORMATION:
SITE WELL ID# (if applicable) 8. SEALING MATERIAL:
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. Water gal.
Bentonite
DWQ or OTHER PERMIT #(if applicable) Bentonite lb. E,L ;V�..�D
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
Type:❑ Slurry ❑Pellets I
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural Water gal. J�'N 20
23
❑ Recovery ❑ Injection ❑ Irrigation Other Ink,-;7441,icii PrrnsaWng Unii
❑ Other(list use) • Type material day soil up to within 36 inches of top of the ground
3.WELL LOCATION: Amount
COUNTY Alexander QUADRANGLE NAME _
NEAREST TOWN: Taylorsville, NC 28681 9. EXPLAIN METHOD OF EMPLACEMENT.OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING: 6'65:6" thick concrete-poured in place
❑ 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 diameterof screens(if any)remaining
LATITUDE 35 49 ' 27.0000 "DM5 OR DD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 81 .12 , 33.0000'DM5 OR DD types of fill materialsised
Latitude/longitude source: jPS ❑Topographic map 3/22/23
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
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 PRVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable) -'()
NAME OF FACILITY 'SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS . ! ;,
.NA Cr-,�3 y f1 -E OF '-I A E ELL OWNE AN ONING THE WELL DATE
City or Town State Zip Code (r a private well owner must be an individual wpersonallyabandons his/her residential well
i accordance with 15A NCAC 2 011 .)
4b.CONTACT PERSON/WELL OWNER: � G �1/.0�t r
NAME Paul & Lynn Dillard PRI ,D NAME OF P RsoA D NING THE WE LL
STREET ADDRESS698 Sam Poole lane
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] I Rev.5/10

_?ems nTfQ,4
. /1/011'711
WELL ABANDONMENT RECORD
,,, 1j -, North Carolina Department of Environment and Natural Resources-Division of Water Quality
`4«u ,,.
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth 56 ft. Diameter:24 _ in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 18 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. 24 in.
City or Town State Zip Code b.Casing Removed: 3 ft. in.
(--)
7. DISINFECTION:
Area code Phone number
2.WELL INFORMATION: (Amount of 65%75%calcium hypochiorite used)
8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable) •
Cement lb. Cement lb.
Water gal. Water qal.
COUNTY WELL PERMIT #(if applicable) F r." --,•..,,r,i ,M�Am
Bentonite o s """ !
DWQ or OTHER PERMIT #(if applicable)
Bentonite lb. JUN 2 a 2023
WELL USE (Check applicable use)❑ Monitoring © Residential
Type:❑ Slurry ❑Pellets
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural Water gal. inkf :';tcn Pr:: : ng link
DWQ/30G
❑ Recovery ❑ Injection ❑ Irrigation Other ,f f ��
❑ Other(list use) Type material 8/00)G� cJJr/i/a K G`i fA
Amount 5% //d -1 C �
3.WELL LOCATION: /, / /
• COUNTY Alexander QUADRANGLE NAME �inl`lc7®u�Zt�r�b c
NEAREST TOWN: 698 Sam Poole Lane,Taylorsville, NC 28681 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
V Slope LI 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 49 • 27.0000 "DMS OR DD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 81 012 , 33.0000,DMS OR DD types of fill materialsised
Latitude/longitude source: E€PS Qropographic map 11. DATE WELL ABANDONED (°/g c;?41 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 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 PBVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable)
NAME OF FACILITY' SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS ejt 7:-; . ,
SIGN•TU--0 'PRIVATE WELL OWN ABA D•`ING THE WELL DATE
City or Town State Zip Code (The pn ate well owner must be an individual wpersonall%ebandons his/her residential well
in a dance with 15A NCAC 2C. 13.) /1Zrl
4b.CONTACT PERSON/WELL OWNER: 11 /1 /1fl
NAME Paul & Lynn Dillard PEDNAMEOFPERSONABANI �NINGTHE WE LL
' ' STREET ADDRESS2167 Hidden Valley road Taylorsville,NC 28681
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