Moore_Well Abandonment_20241025

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# A.3 7? nd
1.WELL CONTRACTOR: i WELL DETAIIS:
a.Total Depth:. / ft. Diameter e in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): f L
�1
/W4t. Lti�� ,eC �©��y�a.(j S LLB Measuring point is �vJ R'above land surface.
Well Contractor Company Name ,/ —�
STREET ADDRESS �Z��f 73 �!zs 6 CASING: Leith Diameter
L(Ie S ir' 47 3-:U• a.Casing Depth(if known): 17 R Z 9"in.
City or Town State Zip Code b.Casing Removed: R in.
/e - &V 3 -ace.z Ali-7—
Area code-Phone number 7. DISINFECTION: -r-�-,- /!Z lh_
2.WELL INFORMATION: (Amount of 65W750/6 calcium hypochlorite used) J
SrM WELL ID#('f appiicableZ & SEALING MATERIAI-
STATE WELL PERMIT#(if applicable] Neat Cement Salad Cement
Cement oZ /z lb. Cemmt lb.
COUNTY WELL PERMIT#(if applicabl Water gal. Water pL- --
DWQ or OTHER PERMIT#(if applicable) der o% % Bentonite
WELL USE(Check Applicable Box):O Monitoring 09esidential Bentonite Sjj p lb 0 r T 2 i-` 2024
❑Mmiaptd/PabGc O Ind O Agriealt rul Type:Slurry_Pellels��
C Recovery ❑hUccbon C Itri�ation Water 931.
oOther(list use)
Other
3.WELL LOCATION: 1A
Type material
COUNTY 1)? 1 QUADRANGLE NAME Amount
NEARESTTOWN: 7-Ylal y
(Stye-7-ad Name.Number,Community.Subdivision,Lot No-Parcel,73p Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAIL-
TOPOGRAPtUC/LAND SETTING- L/
0[351 pe !Walley OFlat ORidge O Other - /4 d
(Check appropriate box) _ / c
LATITUDE 3 4Li z ' 3 'l May be in degrees, '�-
- ®roes,seconds,or in a
decimal format
LONGITUDE 10. WELL DIAGRAM Draw a detailed sketch of the well on the back of this
Latitude/longitude Source: ❑GPS OTOpographic map form showing total depth,depth and diameter of screens(ifany)remaining
(Location ofwell mast be shown an a USGS topo map mad in the well,gravel interval,intervals of casing perforations,and depths and
attached to thisform irno(using GPS.) types of fill materials used
4a.FACIL 17T The name of the bwmew where the well is located Complete 4a amd46. 11. DATE WELL ABANDONED
(1f a residential well,skip 4a;complete 4b,well owner information only_)
FACH,=1D#(if applicoc) I T 115A NY CFRT[FY THAT THIS UC L WAS ABANDONED D ACCORDANCE
/t1cx _ �M ISA NCAC 2G WELL CONSfRUCIiON STANDARDS,AND THAT A COPY OF
NAME OF FACILITY �'� fin/ L L+i}/i THIS REC07HAS BEEN PROVIDED TO THE WELL OWNER
STREET ADDRESS �C"q ' G p
� firA
Tgwm SII�IATORE OF CERTH+IED WEI.I.CONTRACTOR DATE
City°`Get e-5 r��� e Zip 6
4b.CONTACT PERSON/WELL OWNER ,217
SIGNATURE OF PRIVATE WELL OWNER ARANDONING THE WELL DATE
NAME :�t-216`/ (Me private well owner Est be an'.di'-.du@l,.bopmmdhEbd.kA.residential well
in aowrdeoce with 15A NCAC 2C.0113.)
STREET ADDRESS
PRINTED NAME OF PERSON AHANDO"U#G THE WELL
City or Town State Zip Code �/ �� 4oeZ1- TW I).g 6--� Z d 1 f
Area code-Phone number W e 5 f Z ('t' 'Tar J -��ga ic
z737a,
Submit a copy to the owner and the ori&W to the Division of Water Quality within 30 days Form GW-30
Attn:Information Managemeat,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 56& Rev.4/06