New Hanover_Well Abandonment_20240123

ABANDONMENT RECORD ~
'rr North Carolina Department of Environment and Natural Resources-Division of Watt r Quality
-
WELL CONTRACTOR CERTIFICATION#
1.WELT;CONTRACTOR: 5. -WELL DETAILS: --
Mee
a.Total Dcpth:��IL Diameter. in.
We I Contactor(Individual)Name b.Water Level(Belot✓pleasuring Point): — R-
��1 V Measuring point is .0 ------ fL above land surface-
Well Contractor Company Name
STREET ADDRESS ')�$ �QCSp�� I 6. CASTING: Length Diameter
1 e I.ayf)e N.C. a899�
a.Casing Depth(if known): ��& in.
City or Town r�ta�e Zip Code
'q( (o ,_ .a3t`�g Op� b.Casing Removed: g,
-Area code-Phone number 7. DISINFELMON: '
2..WELL INFORMATION: (Amount of 659/a 75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL: -
STATE WELL PERMIT#(if applicable) Neat Cement Snnd('em�n4!,
COUNTY WELL PERMIT#(if applicatile)�P�. (�
Cement lb, cement lb.
Water gaL Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Chc,*applieableuse): ❑ Monitoring EIAWidential Bentonite lb..
❑MunicipaltPublic ❑ Industrial/Commercial ❑Agricultural i t Type:(]Shury Mmelets
[I Recovery ❑Injection ❑ a I do -- f;_ - Water gaL
4 E 3 t r
❑Other(list use) Other
A
J� v .� 24 . Type'maicrial '
3.WELL LOCATION:
Y
COUNT V�,�
UADRANGLENAME_
NEAREST TOWN:
9. EXPL N METHOD OF FMPLACE NT OF MATERIAL:
IV
(StreetlRflaaName,N®be,Community,Subdivision,Lo No:;Parce'?rgCad`e) ; 1 '
4.
TOPOGRAPHIC/LAND G: ;
[]Slope ❑Valley Ridge❑Other
(Check appropriate setting)
WELL DIAGRAM:Draft a detailed sketch gf the well on the back of this
y n degrees,
LATITUDE Ma Ire i d owife'total depth,depth and diameter of screens(if any)remaining
— minutes,seconds,or in a
IANGI I IJDE decimal.frumat in the welt;gravel intcrvA.intervals of casing perforations,and depths and
_— - types off niatcriafsused_
Latitudellongitude source: ❑GPS ❑Topographic map
(Location of ueR-must be shoWR on a USC-fopo waf aiid l 1. DATE WELL ABANDONED �1-—
affached to t6rsform ifnat.rcring CPS) ..
eu
I DO HEREBY CERTIFY THAT nns WELL WAS ABAN -NED IN ACCORDANCE
4a FACILITY The name of the business where the wcU is locar«L Complete 4a and4b, WrM 15ANCAC 2C,WELL CONSTRUCTION STA $,AND THAT A CONY OF
ilfa residential well,skip 4a;complete 40,welt owner irrfommtion only.) THIS RECORD HAS BEEN PROVIDED TO 1Ti LL OWNER.
FACILITY ID#(ifapplicablc)
NAME OF FACILITY r 4C )
SIGNATURE OF CERTIFIED WELL CQNTRACTOR. DA
STREET'ADDRESS'-
" City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner mast be an iAdivido.dwho asa abandons l b&ar residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15ANCAC .0113.j
NAME Ca I y t4 U� J
STREET'ADDRESS- 1.GY� 5 � PRINTED O PERSON ABANDONING THE WE
r ' C - .
_'Submit a copy to the owner and the original to the Divisioa.-of Water Quality within 30-days-Alto:Ifornmtim Mnagement,1617 Mail'Strvi C Form OW3 0
, ag , - , oneo.(99),733-7015eat568. Rev 5106

' �Ca acke-lam Slq

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WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
=- WELL CONTRACTOR CERTIFICATION##
I.WELL CONTRACTOR: 5. WELL DETAILS:
y (�
l iS e- 5���v a.Total Depth: r '60 ft. Diameter. in.
Well Contractor
tr dividual)Name b.Water Level(Below Measuring Point): '3 0 ft.
G� m Measuring point is—i—
g po � . ft.above land surface.
Well Cdlltractor Company Name
STREET ADDRESS _ZQ fo/"t rt•Ve. 6. CASING: Length /{Diameter
cc q { l-e-� A�W y t` '`J'6' Z���I a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
`��- 2:3/- 6()&? -y-
Area code-Phone number 7. DISINFECTION: 1
2.WELL INFORMATION: (Amount of 65%75"/o calcium hypochloritc used)
SITE WELL.ID#(if applicable) 8, SEALING MATERIAL:`
STATE WELL PERMIT#(if applicable) Neat f ement Snnd Cement-
COUNTY WELL PERMIT#(if applicable) Cement lb. Cement lb.
Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ❑ Monitoring Residential Bentonite (rj(J lb,•
❑MunicipaUPublic ❑industrial/Commercial ❑Agricultural•a-G � Type:[I Slurry Pellets
_ Y
[I Recovery [I Injection ❑Irrigation a �_` 'c� �^' 7 i J ' Water- ((� gal.
❑Other(list use) J A N 2 V 2024 Other :
�i1. Type material
3.WELL LOCATION: �r In .',-r:-.!�-n :..
1 ACV f/lbk VJ.�OcJ
r� Amdaat
COUNTY__,�ZITADRANGLENNAME,
NEARESTTOWN: I J I`K Inct n \
9. EX LAIN METHOD OF EMPLACEME T OF MATER AL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND G:
❑Slope ❑Valley Flat ❑Ridge[I Other _
(Check appropriate setting)
10. WELL.DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE Maybe in degrees, form showing total
— — minutes,seconds,or in a g depth,depth and diameter of screens(if any)remaining
LONGITUDE decimal format in the well,gravel interval,intervals of casing perforations,and depths and _
—— types of fill materials used. I.
Latitude/longitude source: ❑GPS ❑Topographic map -3
(Location ofwell must be shown on a USGS topo map and 11. DATE WELL ABANDONED )
attached to this form ifnot 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 15ANCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(Ira residential well,skip 4a;.wmplctc 4b,well owner information only.) THIS RECORD IAS BEEN P OVIDED TO.THE WELL OWNER.
FACILITY ID#(it applicable)
5
- i
NAME OF FACILITY • _ y�-a .
SIW4A`FWE OF CERWIED WELL 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 individua(wha am"Iy am" abandons hislhcr residential well
4b.CONTACT
PERSON/WELL OWNER: in accordance withISA NCAC 2C.0113.)
„ ^(�
NAME {I C`��1/� �7�j / t'l l r�STREET ADDRESS t--`7 C �c��j u 1 c\., PRINTED NAME OF PERSONABANDONING 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] hest%& Rev.5106

WELT,ASAND -law
North Carolina Department of Envinonmentand Natural Resources-Division ofWater Quality
WELL CONTRACTOR CERTIFICATION
'I.WELL CONTRACTOR: S. WELL DETAILS;
a.Total Depth: .'70 .;I't Dienieter. Z in,
Wen Contractor(Individuan
II 1 r b.Water Level(13elow Measuring Point):
V1[/'I /L Mewtuingpoint is. .... S.above land surface.
We`u t oitfiacror Company Namue
STREEGTADDRESS 1 �()M hVe- ' 6. CASING: Length Diameter
�`"'� P • u '—t U.Casing Depth(if known): �%lJ R �in.
City or Town a Zip Code b.Casing Itcmoved: R in.
Aces code-Phone number ?. DISINFECTION:
2..WELL INFORMATION: (Amount of 650/6•75%calcium hypochlorite used)
SITE WELLID#(if applicable) $, SEALING MATE RIAL•
STATE-WELL PERMIT#(ifapplicabk) . _Nest Cement Sand Cement'
COIINTY WELT.PERMIT#(if applicable) Cement .. lb,, Cement lb.
- Water gal. Water - gal.
DWQ or OTHER PERMIT It(ifapplipbk) Bentonite
WELL USE(Checkappliicableuse): ❑Monitoring A Residential Bentonite
❑Movddl)W uhilc 0 lndustriW,Commerew El Agricultural Type:[I Slimy Pellets
r a C+ t" r �1 ' Wa�ga1
Recovery l]IgjectIon ❑Irrigation 0• .9
(]Othei(listuse) � Other -
20.241 Type material
WELi;LOGATION• llliv:e r:'c^il •
n Amdtint
COilN1 Inc ADRANOLE NAME
D:va�
NEARESTj TOWN: Wt( t V�
9. EXPLAIN METHOD OF PLACEMENT OF TE
u.r . u c�vt yC1�M
(Sdr�NRoa3Nama,Ntm�be,Cammauty,Subdivision,Lot No.,Parcel,Zip Code) _� .�( �"'Xc 02
TOPOGRAPMC 11 AND SETTING:
❑Slope ❑valley O Fiat EI Ridge❑Other
(Check appropriate setting,)
'10. WELL DIAGRAM:Drive a detailed sketch of the well on the back of this'
LATiTUDH° _ _ a inar a farm showing total depth,dTth and diameter of screens(irony)remaining
LONGnUDE decimal knout m the wcV,.gravel interval,intervals of casing perforations,and depths and
' - _.— types of fil(matcrials,ucd. i .. - -
Lstttitde/[oaglhide-soarce: GP5 ❑Topographie map
(Location afwaff must be shown on a USGS topo map and ]I. DATE WELL ABANDONED
attacked to th-form ifnot using GPS.)
I DO HEREBY CERTRY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY,The naive ofthe badness whm the wolf is located.COVIetc 48 snd46. WITH iSANCAC 2C,WEIL CONSTklXM014 STANDARDS,AND TRAT A COPY OF
(Ifa-kienthi wall,skip 4a;co�ete 4b,well owner fi&mmtion only) THIS RECO OVID D TO. E WELL OWNER.
FACILITY ID i licable t
NAME OF FACILITY
SIGMA OF RTIFIED CO k17
STREETADDRESS RACTOR J DATE.
City or Town State _rp Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DACE
4b.CONTA:CT PERSONl,WE1f,L OWNER: fMcP�woUawaamust be an Mvldgafwho r�e�sanalivabandons L°/lterrts(dc°Nal well
inaccwdaace'wddi 15ANCAC2C.0113)
NAME :1Ma-I � Cx ,�1 f M1 CKOLc1 a5�
STREET ADDRESS, l d�• t PRUGIT D NAME OF PERSON ABANDONING THE WELL
-
t 3VI
Subrnit a copy to the owner and"the original to the DIvisdan-of Water n Q duty within 3o aaya ti Focus<lW 30
Auto:Information Management,1617 Mail Service Center_Raleigh,NC 27699-1617, Phone No.[phone] eat 568. Rev.5106

r.
WELL ABANDONMENT RECORD
^�
North Carolina Department of Environment and Natural Resources-Division of Water Quality -
b= w WELL CONTRACTOR CERTIFICATION# j
-1.WELL CONTRACTOR
5. -WELL DETAILS:
1 a Total Depth: $. Diameter., ci
in.
Well Contractor(Individual)Namg b.Water Level(Be ow Measuring Point): _ft
V'Cl Measuring point is --_. fL above land surface.
Well cohir
11cf0--r—com-pany Name
Q
STREET ADDRESS 4 5�S Pf A C'jyj�11�"1_T� 6. CASING: length Diameter
LAn i nNe 0. C l n 9"lQ'` a.Casing Depth(if known): fL in.
City or Town State Zip Code b.Casing Removed: fL in.
Area code-Phone number 7. DISINFECTION-
- b _HTH
2..WELL INFORMATION: (Amount of 65%•75%calcium I ed)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable) a — Cement" lb. Cement 1b•
' Watci• gaL Water - gat.
DWQ or OTHER PERMIT It(if applicable) Beotonite
WELL USE(Clieclrapplicableuse): ❑Monitoring ❑Residential eutonite Ib:
0 MunicipaMblic ❑Industrial/Commercial ❑Agricultural Type:❑Slurry (]Pellets
`[]Recovery. ❑Injection ElIrrigation _ .� , G r�° if,. G� 0 Water gat
❑Other(listuse) -- JAN 2024 Other
Type material
3.WELL LOCATION:
Amdfint
vef
COUNTYALtQ 'Q�jj bRANGLE NAME ^
NEAREST TOWN: �1't � - . .
n 9. EXP N METHOD OF EMPLACEME OF MATERIAL
ee :
' (Strt/Road Name``Numbe,Community,Subdivision,Lot No.,Parcel,Zip Cudd)
TOPOGRAPHIC I LAND SETTING:
❑slope [ valley ❑Flat ❑Ridge❑Other `
(Check appropriate setting)
LATITUDE Iu1aq be in degrees, 10. WELL,DIAGRAM:Drti w a detailed sketch of the well on the back of this
_ _ form showing total depth,depth and diameter of screens(if any)remaining
LONGITUDE decirinl fomoat in the well,gravel interval,intervals of casing perforations,and depths and
• types offill materials used.
Latitadeltongitude source: ❑GPS ❑Topographic map =
(Location 00TH must be shown on a USGS topo map and JI L DATE WELL ABANDONED -AA
attached to thisform ifnot using GPS)
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY,The name ofthe busing where the well is located.Complete 4,and4b. WITH ISANCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
ilfa residential well,skip 4a;mmplete 4b,welt owner infommtion only.) THIS RECORD S ROVIDED TO 111E WELLO
FACILITY ID,#@Fapplicable).
NAME OF FACILITY
SIGNAT RE OF CERTIFIED WELL CONTRACTOR DATE
STRM ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The pmotc well owner rut boon Mvk kmrwho oe;awliv abandons his/her residential well
4b.CONTACX PERSggO�N�IW. ELL OWNER: - in withl5ANC C2C.0113.)
NAME k!bp D=y { L. Q ifsTRW,r ADDRESS. (r PRINTED NAME OF PERSON ABANDONING THE WELL
INY1
Submit a copy to the owner and'the original to the Division of Water Quality within all days..` Form GW 30
Attn:Information Management,1617 Mail Service-Center—Raleigh,NC 27699-1617, Phone No.[phone] cat 568. Rev.5106

WELL ABANDONMENT RECO .
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 4 I I -�
I.WELL CONTRACTOR: 5. •WELL DETAILS:
-- Kk_ � � •�• � a.TatalDepth: t Diameter
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): R.
SA0,P_ VrtIGllw cklle PfAMP ServtLQf Measuring point is-�-�.._. @.abovelandsurFece.
WelMontractor Comparp��Name -
STRW ADDRESS �"'-1--=�1 1— Uf 6. CASING: Length Diameter
V �q a.Casing Depth(if Imown): _ !�& `I in.
r I City� or.Town S t Zip Code fL �1— .- •a3 i- b.Casing Removed: 1 in.
Area code-Phone number 7. DISINFECTION•
7—WELL INFORMATION: (Amount of 65*6-75%calcium hypochlorite used) `
SITE WELL ID#(ifapplicable) 8. SEALING MATERIAL-
STATEVELL PERMIT#(if applicable) 151eat Cement Sand Cement
COUNTY WELL PERMIT#(ifapplicable) Cement lb. Cement lb.
Water gal.. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Chcckapplicableuse): ❑Monitoring Residentini Bentonite lb.
❑MunicipaMblic lndustrial/Commerew ❑Agricultural Type:0 Shnry l eilets
EI Recovery '❑Iajeetton ❑irrigation Water_gaL
D Other(list use) >`= ^' <,a � 9 Other
J A N 2 V L r 24 Typo tnaferial
3.WELL LO�rCAT,I�\�ON�":• U
COUNTY I� N �P*§"Q Amount
UADRANaLE t1 nAME_ ;gin
NEAREST TOWN: W Miq ( ^^ G•r`�15`=
MI�S� M�SSiO W� ��O l7J 9• EXPLAIN METHOD OF EMPLACEMENT FMATERIAL:
►� N�Irs D. E-lydia-1�2
(Saoet/RrodNeme,Number.Community,Subdivision,Lot N e)
TOPOGRAPHIC/LAND SETTING:.
❑slope O Valley []Flat (]Ridge[ Other
(Check appropriate setting)
LATILATITUDEseconds, "10. WELL.DIAGRAM:Draw a detailed sketch of the well on the back of this
minutes, or in a
May fort showing total depth,depth and diameter of screens(if any)remaining
— —
LONGITUDE deciaml fammt in the well,gravel interval,intervals of casing perforations,and depths and
—— - types offill matcrialsused. --
Latitude/longitude source: -(]GPS t]Topographic map '� '
(Location ofwell must be shown on a VSGS topo map and 11. DATE WELL ABANDONED
b
v .2oZ3
attadied to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WA AB IN ACCORDANCE
48.FACILITY,ITY,7Tie name of the business where the well is located Complete 4a and4b. W ffH 15ANCAC 2C,WELL CONSTRUCTION Sr,A S,AND THAT A COPY OF
ilfa resklential well,skip 4a;complete 4b,well owner infommtion only.) THIS RECORD S BBBN PRO DED TO THE 1.OWNER.
FACILITY ID#(ii applicable) - t
NAME OF FAC1LffY
STREET ADDRESS SIGNATUFS OF CERTIFIED WtLL CONTRACTOR DATE
Cityor Town State Zip Code SIGNATURE OF PRIVATC WELL OWNER ABANDONING THE WELL DATE
46.CONTACT PERSO ELL O R (Me Pdvwe well owner most bean MvIdudwho mmllyabaadona bMw residential well
inaccotdance'wif15ANCACZC 0113.}
NAME_ Fre��.5�c't� Lee J� � . (� I. e. saq� • .
STREET ADDRESS 1.� �j t(� • �S {�S PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner aml'the original to the Division of Water Quality within A days. Form OW 30
Attn:lnformadon Management,1617 Mail Service Center—Raleigh,NC 27694-1617, Phone No.(919)733-701I eat 568. Rev.5w

v
SEA
wELi.ABANDONMENT RECORD
North Carolina Departrntnit of Envimnmrrif.wd Natural Resources-Division of Water Quality -
WELIXONTRACTOR CERTIFICATION ij
L WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth:96 Diamcicr. m.
Well Contractor(Individual)Idamc b.Water Level(Below Measuring Point):-��1_fL
6V1 Measuring point is _. 1 above land surface,
Well Contractor Company Name A
STREETADDRESS_- �$ LM J`t 1 6. CASING: Length Diameter
\ t a.Casing Depth(if known): _tt in.
City or Town - State Zip Cade
b.Casing Removed: in
Area code-Phone number- - 7. DISINFECTION-
• 2..WELL INFORMATION: (Amount of65°/r75%Flcium by ochlonte used)
SITE WELL ID#(ifapplicable) 8. SEALING MATERIAL-
STATE WELL PERMIT#(if applicable) Nest Cement Cnad Cement
COUNTY WELL PERMIT#(if applicable) Cement lb. Cement lb.
Water gal Water gnl.
DWQ or OTHER PERMIT#(if applicable) Bentonite ,
WELL USE(Checkapplicableuse): ❑Monitoring esidentinl Bentonite OIOO lb.
❑Municipal/Public ❑lndustiial/Commerc_iai ❑Agricultural Type:Q Sh-y 1§ ellets
❑Recovery El Infection ❑Irrigation" `t_,�'. ;"r— Water ; 6 gal
0Other(fist-use) Other
"' 24 Type maferial
&WELL LOCATION: f n; „;;.•-�n :�," - Amount
COUNTY �UADRANGLE
NEAREST TOWN: gq t
9. LAIN METHOD OF EMPLACEMENT OF MATERIAL:
r
(Street/Road Name,Number.Community,Subdivision,Lot No.,Parcel,7rp Code) \
TOPOGRAPHIC/LAND.SE CI1NG: -
'�pe 0 Valley -0 F1at ❑Ridge(]Other
(Chcck,app►"opnit6 sFttiu9)
10. WELL.DIAGRAM:Draw a detailed sketch of the well on the back of this
Maybe in dcgmcs,
LATITUDE — _ remotes,seconds,or is a form showing total depth,depth and diameter of screens(f any)remaining
LONGITUDE decimal format in the well,gravel interval,ititeivals of casing perforations,and-depths and
types offill materials used. ! -
Latitude/Mngitude source: -0 GPS ❑Topographic snap r\0
(Location ofuv l mast be shown on a VSGs topo map and 11. DATE WELL ABANDONED
attached to thisfain ifnat UsingGPS)
4a.FACILITY,ThI DO HEREBY CERTIFY THAT THIS,WELL WAS ABANDONED IN ACCORDANCE
e name of the business where the wets is located.Complete 4a and4b. WITH 15ANCAC 2C,WELL CONSTRUCTIOTI STANDARDS,AND THAT A COPY OF
yfa residential well,skip 4a;complete 4b,well'owner ia%nnagon only.) THIS RECORD HAS BEEN PRO DED TO THE WELL OWNER.
FACILITY ID#(i>applicable) g 2 t
NAME OF FACILITYVA L
STREET ADDRESS
SIGNATURE OF RTWIED WELL CO3NTRACTOR DATE
- -
City or Town State VP Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must bo an Mvidvafwho oen nno JiM abandons hislhcr residential well
4b.CONTACT ERSONNVELL 1 ER ma with ISAN/�,p
CAC2C.0113. /�
NAME ��(1ho l i C-t Sal,
STREET ADDRESS. -I Ot PRINTED NAME OF PERSON A13ANIDONING THE\YELL
Submit a copy to the owner and the original to the Division of Water Quality within 16 days. Form GW 30
Attar Information Managimtent,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.(919)733-70i15 est 568. Rev.5106

-WE ILL ARAN_DO N_, RECO A
Noh Caolin Departrnent ofEnvironmnt and Natnd Reoutxs-Divlston ofW{a ter QuttlitY -
:-,•E, WELL CONPRACPORr CERTIFICATION##
1 1?i' L.CQNTItAC7OR: wELLr. I _
O ;& Diameter.
CoNractor(Individaal)Name a Total Depth: in.
e P S b.ManuringLml(Below Measarmg Rmabove land surface•
1 - urinS point is.� ��
Weil Contractor Comp Narme/ d p'
87REErADDRESS .off`C TO� !►�` 6. CASING:
iLengBi, Diameter
City or Town State Zi Code CIAa casing Depth(if tmown): -ft, in.
p b.Casing Removed:
Area code-Phone number ?. DISIIVFECTTtIN• ! I
L.WELL INFORMATION: (Amount of 65%•75%calcium hypochWte use!) ,
SITE WELLID#(if applicable) tl. SEALING MATERIAL:.
. I -
---3TATI?i?WSId.PERMIT#(if applicable) - 4 (Neat(`errienf8ttd S'e -
Cement Ib. Ccauent lb. ;
COIINTY WELL PERMIT#(ifapplicabh;) _
Water•7, Water '- __gat
DWQ or OTHER PERMIT#(if appligbk) Bentonite
WELLUSE'(ChecicsFplicableim): I-] @ Bentortite 55
❑MunidpaMblle []InduslriaT/Commerciat cultural Type:[]Sl�urr/yam SPdreets-
El Recovery, ❑Inf ecftog--0 Ir7ig9tiOn ".��, j' i '� Wafel' J•:.�],. -
❑Other(listuse)---_-,. Other
��-���� 2024
Type mahaial '
3.WELL LOCATION: �n; •rc;..°wn 'r ;.-,
��� E P Amdtint
COUNTY QUADRANGLE NAME 7':
• 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(SheetlRoadName,Nombey C-oo-ity.Subdivision,[At No.,Faecal,lap cone) . 01
TOM)GRAPFUC./LAM F0
OSlope, []valley ❑Ridge
El00 r
( arp. settino
TV
10. WELT.DIAGRAM:Iltmv a detailed sketch of tho well on the back of this
Maybe in dcgW14TTUDE - form showing total
� . nduetofcesOyy)drina "
LONGFIiDE ts
in 8te.vl ell,gravel intetval;mtcniatc of casing p14f;_orafions,and depths and
- _ _ _ -' _ _=• _ ---__- --types:o€fillmaterialsv�J.- �-.- -. - - -- - -_- -- -
La`tituitello'ngitnde soerce: ❑GPS []Topographic map Y
(LoeWon ofxeA mus(be shomr on a USGS t 11. DATE WELL ABANDONED': , ..
auarJwd to d-form iJ'not—94GPS) _
I DO HEREBY CERTWV THAT MBS WEILL WAS ABANDOM IN ACCORDANCE 4a.FACHATYdmm name ofthe business whine Me well is heated.Complete4a and4b.• WITH ISANCAC 2C,WEM CONRXICTION STANDARDS.AND TMT A` _ OF
(ifa a•sidntisl welt.skip 4a;mmpf�e 4(�Well owner i ion only-) THIS RECORD HAS§EEN9LOVIDED TO.7W WELLOWNER•.
FACILITY-W#(i>applicable) -
NAME OF FACILffY
SIGMA OF CERTIFIED VVEM117C
WMIACTOP* RA7B,
STREEPADDRESS
City or Town State Zip Code SIGNATURE OF PRNATS.WELL OWNBR ABAiYDONING THE WBLL DATE
(Tbepiiva�weIIowoermiistbeanadivalgafwho abaddonhbJhernesiden&1well
46:CONTA PON/WELL•-O ! iaaccozdmx &15ANCA 2CA )`•
NAME CD I O4 -
STREET ADDRESS. R, pRMM N'Mft OF PERSON ABANDONING Tl _WELL
Submit a copy to the owner and-the original to the Divlston-of Water Quality within 30 ; -
days. Form QW-30;
Attn:Informatlan Msuagemenk 1617 Mail Service Centex-Raleigh,NC 27699-1617,,,Phone No.019)733-7015 eat 568' Rev.5166

_WKlal AIAJL��P 1-JRE! .
s : North Carolina Depamumd of Environmem and Nahnul Resources-Division of Water Quality. -
. WELL CONTRACTOR CER77FICATION
1.WELL CONTBACTOIL•
� 5. -WELL DETAU.91. d
w, �l(Indeal)Name al-- a.ToW Depth: —95 I S. Diameter, a in.
ontractor i"
f n b.Water Level(Below Measnting Poiatj:.a! it,
]J 1- � If l)t� 1C Mcmuriug point is. „. ft.above land so&=
WellConttacmrCom"p Na/me
STnWADDRESS `C 1 O ! ►� 6. CASING:
Diametee.
•�— --1.CttyorTown State Zip Code m Casing Depth(ifk •)nown• �ft.
b.CasivgRemoved:. R in
Area code-Phone mtmber 7. DISINFECTION-
L.WELL INFORMATION.-
SITE WELLID#(;fappScable) R, SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) _ • Neat Cem-:.tom-ten
COUNTY WELL PERMIT#(ifapplicabld � Cement Y Ib. Cement- �1b.
Water !' Water - PL
DWQorOTH=PERM[T#(ifapplipbtcj
WELLUSE(Chedcapplicablense): p Monitoring Bcntonite Ib.
❑MamicipaUPobIIc p indlastriaUCommeretalm {grJluntputnl _ Types❑S_h y eAets
O Recovery ❑InjecHo�0 irrigation �: i.r,' 0�.r;, ' Water �—gaL
❑Otheroistme) JAN 2 -S 2024 Other
&WELLLOCATION:
Atndtint
COUNTY ADRANGC.B NAME
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL,
t (> r —.
W
isneetRaedName,N®beSC--miq,So6divry i .,LotNo.,Pan:ei.TipCode)
TOPOGRAPMC I LAND
LL E(aw
pSlope 0VaHcyjjffkWC7RiagcOOgw
(Check aFp Wiaw setting)
10. WELL,DIAGRAM:1$raw a detailed sketch of dm well on the back of tbis
LATITUDE _ �'� form showing twat depth,depth and diameter of scroens(If my)secands,orioa ( aay)t+emniniog
LONGMIDE decimal t. in the well.gravel interval,intervals of casing perforations,and depths and
—— - types offill materialsused
- _ Latitadchongttude soaree:__pGPS=_p T pogtmpWe.tuap-
(Location ofwelf nnw beslaoavn on a USGS fopo»tap mad 11. DATE WELL ABANDONED,
attadted to dwform lfnot arsitrgGPS.)
4a.FACII,ITY,The a urae oftbe business wlmfe rim well is iaeated I DO HEREBYCFRTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
ComPkte4a aad9b VMH iSANCAC 2C,WELL CONSMUCTION STANDARDS,AND IRAT A COPY OF
Or;k msidmitW well,skip 4g,eompldc 4k well owmrinfmmatioa unly) THIS RECORD HAS 8H8N PROVIDED TO THE WALL OWNER.
j IACH,ITY ID#(ifappbvblc) t
NAME OF FACU ITY
"TUIM4
CTOR Q Cd7
STP"ADDRES$ ,
City or Town State Zip Cade SIGNATURE OF PRNATE WE61 OWNER A&MMMING THE WELL DATE
46:CONTA �')�SpN/WFdd,O [Egg - inaccoivatcewithISAer WCt6eaainIS.) fwho a6a�onahisllertsfdmNatwcll
�tLYt.7• maccoidnoce'q��ISANCAC2CAl13.),
NAME ����L._�. ��� � • -
STREET ADDRESS R. PRM"NAME OF PERSON ABANDONING THE WELL �—
Submit a copy>p the owner 8nd-*e original to the Division-of Water Qua*within N days. Foam ow30
Attn:In&.ri6tlon alm%men%1617 Mail Service Cearter—Rddgh,NC 27699-1617, Phone No.[phone] eat 56& Rev.5106