Stokes_Well Abandonment_20231113

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ti. 4ATE •
k 1 . _ WELL ABANDONMENT RECORD
A t''r North Carolina Department of Environment and Natural Resources-Division of Water Quality ` '
,..`-- WELL CONTRACTOR CERTIFICATION# .�' .,2. 4'`_ d.;" '
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1.WELL CON/TRACTOR) S. WELL DETAILS: 1 O`/ ,' 2023
a.Total Depth: Sk....5 " ft. Diameter .in.
Well Contractor(Individual)Name / b.Water Level(Below MeasiuingPoint): 9$ `
# ft '.�,; . A:i
Ln phr i!•%' SM A weft CO' AG- Measuringpointis 0 it.above land surface.
Well Contractor Cmnpfny Name
STREET ADDRESS to 3 bi a...k t.c e.) 061P. 6. CASING: Length Diameter
MQi0da_N MC- � 7002?
a.Casing Depth(if knoam): 0 it © in.
City rTown State Zip Code b.Casing D R 0 in-
( 33L )- if a7 - 10
Area code-Phone number • 7 DISINFECTION: W%J! ca.C S
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL 1D#(if applicable) - -- -- - & SEALING MATERIAL:
STATE WELL FERMIT#(if applimble) Neat CemPOL Sand Cement
CeCOUNTY WELL PERMIT#(ifapplicable) 3 q!'0 W t ent lb. Cement lb.
Water gal., Water gat.
DWQ or OTHER PERMIT p(if applicable) Bentonite ,
WELL USE(Check applicable use): 0 Monitoring gResidential Bentonite lb.
❑Manicipal/Publc 0 Industtial/Com nercial gl Agricultural Type:❑Stony ❑Pellets
❑Recovery 0 Injection ❑Irrigation Water �'
` Other
❑Other(list use) Q C/�
Type material I !%x
3.WELL LOCATION: • Amount 5'57 N r IS
COUNTY S TAkeS QUADRANGLE NA/ME •
NEAREST TOWN: SA--AG P;/X i
�/ n y J /, . 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
n An.c iTbain iGC , o�7bz 4- b,,, h. er• `d- CI ,..?c.Gj< ClCi
(Street/Road Nam,Number.Cotnaenity.Subdivision.Los No.,Parcel,Zip Code)
p 3,470 , G,�rl i e r- DLL C/4 IL,c
- TOPOGRAPHIC/LAND SETTING: /ac t (de an.Gvt, f" Cat. e ii.p1 a�
❑Slope ❑valley .Flat ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATI UDE / Maybe In dTeds7,
°3 t �3 seconds,ar w a form showing total depth,depth and tfiameter of screens(if any)remaining -
9 0 t deea®i format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE W D Q er, �Z types of fill materials used.
Latitudelongitudesource: „FfGPS ❑Topographicrna
P (� �j
(Location ofwell must be shown on a USGS topo map and 11. DATE WELL ABANDONED / - / - M
attached to thisfonn ifnot wing GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Camplete4a and46. WITH ISA NCAC 2C.WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF
(Ifa tesideatia!well.skip 4a:campkte4b.well ownerinformatioa only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(ifapplicable) I p
NAME OF FACULTY �sd e j LS 8 v I /ra.,•!„5 / - 7:2�
SIG FCER WE CONTRACTOR DATE
STREET ADDRESS
Sa- .2y I c l(`- ,270ite
City or Town/ Mate Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
4b.CONTACT PERSON/WELL OWNER: f1bprivatep11e well owner must be an individual who personally abandons Irislherresidcatial well
in accordance with ISA NCAC_C.0113.) 1 /_
NAME AlKaid /gP%G` hea, t� JoA,►` PA•/iP S-41 / T
OQ , PRINTED NAME OF PERSON AB ONING THE WELL
STREET ADDRESS GO! h S it' t.9 h
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Submit a copy to the owner and the original to the Division of Wafer Quality within 30 days. Form GW-30
Attn:Information Management,1617 Marl Service Center—Raleigh,NC 27699-1617. Phone No.[phone] ext 568. Rev.5/06