Iredell_Well Abandonment_20230912

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,r s WELL-ABANDONMENT RECORD
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li' _d .,. c i. North Carolina Department of Environment and Natural Resources-Division of Water Quality
.7."- ,-; WELL CONTRACTOR CERTIFICATION# 26 a a-A
1.WELL CONTRACTOR: 6. . WELL DETAILS: �� ' '
C /U 24'd,-5 a.TotalDepth 68 ft. Diameter. in.
Well Contractor(Individ al)Name b.Water Level(Below Measuring Point): ft.
sL) ,,, sue Measuring point is i U ft.above land surface.
Well Contractor Company Name ,�`�
i?�Y� , ,,// /?/2/ 6. CASING: - . , Length Diameter
Street Address , l�/,4
� / ,�a� G"l a.Casing Depth(if known): ft. '' in.
yo y��Y a/L e l de b.Casing Removed: �c• /1 ft. in.
City Or Town 7 State Zip Carle
('7/7 ) '1iii 7- DISINFECTION: 3 .6 z
Area code Phone number
(Amotllnt of 65%75%calcium hypochlorite used) •
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2.WELL-INFORMATION: 8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
NEatCpment Sand Carnppt
STATE WELL PERMIT# (if applicable) Cement i lb. Cement lb.
q ) Water I. gal. Water gal.
COUNTY WELL.PERMIT #(if applicable) _ a'S1
Bentonite , s-+
DM or OTHER PERMIT#(if applicable) i p (.,i.;
Bentonite / lb. i[ , f"
WELL USE(Check applicable use)7 Monitoring ftr/Residential Type:❑Slurry ktiellets 9
0 MunicipallPublic L lndustriaUCommercial •i7•Agricultural Water gal. SEP 1 2 2023
0 Recovery El Injection D.irrigation Other - In►orca.aVcnpfr.,-''.� • Ili-;
Q Other(list use) Type material
Amount
3.WELL LOCATION:
COUNTY 149-/(^QUADRANGLE NAME
NEAREST TOWN: ! ,s'G f�✓h -� 9. EXPLAIN METHOD1OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Coda)
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TOPOGRAPHC/LAND SETTING:
Slope 0 Valley D Flat 13 Ridge°Other I
(Check appropriate setting) 10: WELL.DIAGRAM:IDraw a detailed sketch of Mizell on the back of this
Li form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 36,J n � 7 "DM5 OR 3X.XXXXXXXXIOD in the well,gravel interval,intervals of casing perforations,and depths and
types of fill materialsised
LONGITUDE 7�L e7 u"�g g� "OMS OR?X.XXXXXX)tXOD -,� (�
Latitude/longitude source: ❑GPS Qropographic map 11. DATE WELL ABANDONED C / .23
(location of well must be shown on a USGS topo map andattached toi
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.
(11a residential wet,skip 4a;complete 4b.well owner information only.)
FACILITY(D# (if applicable) Al..4.../-SIGNATURE FLED WELL CONTRACTOR DATE
NAME OF FACILITY .
(^e_.. .te`".
STREET ADDRESS I
SIGNAT.UREOFPR ATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Tap Code - (The private well r must be an individuatwhersonalllebandons his/her residential well
in accordance with 15A NCAC 2C.0113.)
4b.CONTACT�/ PERSONIWELL OWNER: � , LOX)r IA o� A.-Alans
NAME }t'e i i n d I3LC..COI' �.-C 1��"" PRINTED NAME OF PERSON ABANDONING THE WE LL -
STREET ADDRESS5daLe' tLL -
Ti ott.t7+.ar! n c. ,
Submit a copy yo the owner and the original to Division Of Water Quality Information Processing, Form Rev.5/0 30
1617 Mail Service:Center,Raleigh;NC 27699.1617,Phone.:(919)807=6300 1