Stokes_Well Abandonment_20230807

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• _ WELL ABANDONMENT RECORD I -,5�..
�.,.IT North Carolina Department of Environment and Natural Resources-Division of Water Quality ''
"- � WELL CONTRACTOR CERTIFICATION# AUG � 'it
iii,i ,7 0
1. L CONTRA Om `' �, f
�i� �'� 5. WELL DETAILS: ' 1' .
t (L'n e a.Total Depth: 6 ft. Diameter AO in. ''C7 9/!,•
Contractor(Iadivl al)Namef - b.Water Level(Below Measuring Point): 4,7(Li ft-
l. ►Y�@ 1�t (_' Measuring point is 0 ft.above land surface.
Well Contractor Company Name
STREET ADDRESS 72PSTed 4a4 Wed 6. CASING: Length Diameter
C., - moo/ A IOC- '27 Ol? a.Casing Depth(if known): `•"•` ft. in.
City or Town State Zip Code b.Casing Removed: .---- ft in.
( .334- 79 Ll:1S>,_
Area code-Phone number 7. DISINFECTION: 3 nZ
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
r— 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): 0 Monitoring ©rsidential Bentonite lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry ['Pellets
❑Recovery 0 Injection 0 Irrigation Water gal.
Other
0 Other(list use) /l
Type material £U i(MtY /'(ifJ'"\
3.WELL LOCATION: Amount /(fZ.- yr)
COUNTY ke._Sm QUADRANGLE NAME
NEAREST TOWN:e S6I-1, i(ue.Cl c,52).76/At) 9. EXPLAIN METHOD OF MPLACEMENT OF MATERIAL:
C7'/ �4C3A � , 27o(9 ( C4/of t, . i I I (AAA fi f r-I- -fD&lt %�,
(Street/RoadName,Number,Community,Subdivision,LotNo.,Parcel,Zip Code) f >!� S U �Le f .O ._ /tA�iej
TOPOGRAPHIC/LAND SETTING: W' to So y 1 t ,,r� (�i t , y`
❑Slope 0 Valley Ilerat 0 Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE b f r! �i 2 U1 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 casing perforations,and dept
hs anddecimal format
LONGITUDE"g© t 231925
types of fill materials used.
Latitude/longitude source: i KI'S 0 Topographic map
2
(Location ofwell must be shown on a USGS topo map and 11. DATE WELL ABANDONED 6- 23
attached to this form if not using GPS.) I DO HEEEBY 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) 7- Zv._33
NAME OF FACILITY,c7 U-fikter C1 .540 1-1140tES SI TURE OF CER D I CONTRACTOR DATE
STREET ADDRESS 72(`' "e_&.k- r /fit
�D
ie sdeck. A,6.- 2. 7(o- ff
ity 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 ace ce with 1SA C 2C 0113.)
NAME IGl_ ( C—
STREET ADDRESS P NAME O 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] est 568. Rev.5/06