04017_Burlington Mills_Report of Environmental Services_20090918

(
September 18, 2009
M!I?;~l~{\~T!~
Engineering & Environmental Solutions
409 Rogen View Court I Rakigh I Norlh CturJ/Jn4 I 27610
800-48(>.7568 I 919-250-9918 I 919-250-9950 FIICS/mlle
www.maaonline.com
Division of Water Quality
Attn: Information Management
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Subject: REPORT OF ENVIRONMENTAL SERVICES
MONITORING WELL ABANDONMENT
MOORESVILLE MILLS
MOORESVILLE, NORTH CAROLINA
MID-ATLANTIC PROJECT NO. OOOR1780.04
Dear Information Management:
Mid-Atlantic Associates, Inc. (Mid-Atlantic) is providing this report detailing the
abandonment of 14 monitoring wells at Mooresville Mills in Mooresville, North Carolina.
Details regarding the installation of these monitoring wells can be found in Mid-Atlantic's
Site Assessment Report, dated November 8, 2001 and Addendum to Phase I Limited
Site Assessment Report and Request for No Further Action for Groundwater Incident
Number 08171, dated March 25, 2002. Both of these reports are on file at the North
Carolina Department of Environment and Natural Resources (NCDENR) Brownfields
Program.
Monitoring well abandonment activities were conducted on September 3, 2009 by Mid-
Atlantic Associates (Well Contractor Certification No. 3339). A total of 14 of the 17 site
monitoring wells were located and abandoned. Three monitoring wells (MW-4, MW-4s,
and MW-7) could not be located. A metal detector and a shovel were used in an attempt
to locate these wells. Field observations indicated that they appear to have been buried
or destroyed during previous site demolition and grading activities. Table 1 provides an
inventory and summary of monitoring well abandonment activities. Attachment A
provides drawings showing the locations of the monitoring wells identified in Table 1.
Monitoring well construction records are included in Attachment B. Monitoring well
abandonment forms are included in Attachment C.
.. ,
.. __ , .... ~-
Monitoring Wall Abandonment
Mooresville Mills
Mooresville, North Carolina
September 18, 2009
Paga2
If you have any questions or need additional infonnation, please contact us at 919-250-
9918.
Sincerely,
MID-ATLANTIC ASSOCIATES, INC.
~~~j§;;;~--
Jeffrey Tyburski, PG, RSM
Senior Geologist
Darin M. McClure, PE
Principal Engineer
•. cc:. Mr. Oliver Pau-Cherokee Investment Services
:. Mr. Tony Duque-NCDENR Brownfields Program
Attachments: Table 1-Summary of Monitoring Well Abandonment
Appendix A-Site Drawings
Appendix B -Monitoring Well Construction Records
Appendix C -Monitoring Well Abandonment Records
OOOR1780.04/Monitoring Well Abandonment RPT-091609
MP?;~l~.T!~
EIINfllttrin~ d: Eru•ironmtnlol Solution!
Certification No. 3339)
Note: Measured depth was recorded at the time of monnoring well abandonment
ATTACHMENT A
SITE DRAWINGS SHOWING
MONITORING WELL
LOCATIONS
MP?s-~l~N'H!~
En1inttring d: E1n•ironmtntal SolulionJ
rJ1
LEGEND
0MW-1
·MW-13
Ill MW-81
esw-1
lllllllllllllllllllllllllllllllll
---·----·----·------<-<----•---.....
(818.521
850.0'
_JJ
I
MONITORING WELL LOCATION
TYPE II MONITORING WELL LOCATION
TYPE Ill MONITORING WELL LOCATION
SURFACE WATER SAMPLE LOCATION
RAILROADS
FENCE
ELEc:TRICAL UNES
PROPERTY BOUNDARY
~
GROUNDWATER FLOW OIREC110N
GROUNDWATER ELEVATION (AT LOCATION)
ESTIMATED GROUNDWATER CONTOUR
GJ
®
® @
•-m~-9~ --
(824.85')
UNNAMED TRIBUTARY~~ 820.0'
OF DYE CREEK •• -SW-1
(818.521"" •• --
0 !'~no
0 0 ..
I ':-
~ "' o-
[i]
860.0'
1155.0'
POTENTIAL CONTAMINANT SOURCE
INVENTORY TABLE
MAP I.D. POTEN1lAI. CONTAMINANT SOURCE
® WASTEWATER TREATMENT FACIUIY, BASEMENT
@) CHEJi!tAL LAB
© CHEMICAL LAB STORAG£ AREA
@ FORMER HYDRAUUC UFTS
® FORIIER VARSOI., GASOLJNE, . DIESEL AND
WASTE OIL UST/AST AREA
® COAL STORAGE AREA
@ DIESEL AST FIRE PUMP
® ~SFORUER AREAS
CD 150,QOO--C.6UON NO. 8 HEA'TING OIL AST
0 MAINTENANCE SHOP
® FORII<;R MAINTENANCE SHOP
(b) RAU.RaAil SPUR, CURRENT AND PRE\IIOUS
® LABORATORY-PHYSICAL TESTING
® GARAGE NEXT TO GASOUNE UST
@ OFF-SITE LUST/GAS STATION
® OFF-SITE. FORMER MILL DRY-cLEANERS
825.0' @ BASEMENT SDILS/STllRAGE AREA
lilliE: SOIL BORING AND MONITORING WELL LOCATIONS BY A.G. ZOUTWEI.l.E SUR'JEYORS .
JUNE AND SEPTENBER OF 2001. HORIZONTAL AND VERTlCAL POSITIONS ARE BASED oN
SANITARY SEWER RIM ELEVATIONS AS SHOWN ON THE LAND TITLE SURI/EY BY GElWJ) V.
GRANT AND ASSOCIATES DATED 12/05/00.
~ 0 0 ~ 0 r-. r-. N N ~ r-. ~ a:: ~ N w a:: ::rn !I] 0 ::::;: 0 w 0 > 0 0 0 0 z z z "'"" w !I] Cl (.!) !;( 3: 0 t3 Cl 0 ....,
\~ ~ ~ f;l "" J: J: u u
0 " ~ "'
z I~ z ~ 3: -8: .. ~ iii c iii ~ iii !1( ~
~ < ::::;: z ...J
3: a.. 0 ci 0 -a:: 0 ...J ~--~() ' LL Zz II)
a:: ~ 3: :r: 0 w c_OI-' 1--: ...... ~ a:: N <ow o ~
3: '-....J~Z (.!) 0 r-. ...J w z~>w~ z
::::l '-Ul a:: ~ o mwuz a:: a:: w ::::l 0::
(.!) 0 ...J 0 Cl Oou (;:j Cl ::::;: Cl w o...J !;( (.) Gl > 0:: ::::;: Cl ::::l i= w Ul Ul a:: w -Ul w !;(
U<~ (.)
0 Ul ~ . -~ Ul ~~:::! < ~~ ~ ~:s 1-z E-1 ij ~ ~-<~ (.!)
~u -~ >
Cl <o~ ...J
lrl.l~ ~ ~rl.l w
(.!)
~-< .. ~ w ~~ (.) z w
0:: w LL. w a::
!.EllEND
IIIIIW-1+
eE-1
L
IIAIIflENANCE SHOP
AIIOI£-GROUND STORAGE TANK AREA
I
llo!lf'aoRINIJ AND IIDNIIDRINO ~ LDCo\liDNS Iff A.O. ZDUJWEI.I.E SURVErDRS JUNE OF :llKI1. HtiRIZONTAl. AND VEHIICAL POS!IIDNS Nil! BASED DN SANITARY SEWER Rill ELEVAliDNS IS SHOWN ON 1HE LNm ll1lE SURVEY BY CI!RAUI Y.
GRANT AND ASSIICIATCS DATED 12/DS/OD. IIW-1+ LDCo\liDN Iff IIID-IiMNIIC
F1EID PERSONEL BASED ON EXISilNQ SITE F£A1URES.
-rY" \
WA1DI
\ TANK
~.A
.llliJES: REF1!R TO TABlE 3.1 FOR
SVOc-5EII1 YOIA11LE OIIGANIC COMPOUND (mg/lcg)
liC.-11ENTA11YELY IDEIITU'IED COIIPOUNDS (mil/log)
DEHP• BIS(2-E1!ftUiEXYI,) Ptm1A!A1E
A DETAASI SUIIIIARY OF
LH!ORA'IllRY ANALYIIES AND ME!HDD DESCIIIPIIDNS.
IIErAI.Sa ma/lcg
MID-ATLANTIC
ASSOCIATES, P.A.
~ Jt EDvimamaiiJ SolatiaDa
REFERENCE:
SAMPLE .LOCATION MAP AND W,WN 1 MTE:
SUMMARY OF
LABORATORY RESULTS-DRAFT n n. JNOO~. FORMER CHECK: )f''ll EAS~N UST AREA r.;;EN:.::G;;;:;:.(I._..r--+~,;....;_-a_1 _-,1-,_-70-,__-03-ll
CHEROKEE:...MOORESVILLE SITE ~CH;.;..EC;..;K:.;;.· -"-··-'+=-:-:0:~. -----it
MOORESVILLE, NORTH CAROUNA APPROVAI.!DM" ro,G
MARCH :1.00:1.
OODR1127 .OJ
2.1
ATTACHMENT B
MONITORING WELL
CONSTRUCTION RECORDS
M!9;~JhfflT!~
£nginttring & Environmtnlaf Solutions
FROM R5D CRR!l..l NAS PH:JNE NO. 71'14 662 1<1678 Jul. 31 2001 1B!24AM P2
NoM Cat011na • tl1111arlmenl or Enlillanmenland Natural Raoaurca. DiviSion Of Water Quality. G""'ndwaler Section
1638 Moll Service Cenlsr· Raleigh. NC 27699-111311 Phone [phone]
WELL CONSTRUCDON R@COBD
WellldDI\tlflaaUon II: MW·I
3. DATE! DRILIBO: l!l1Ml1
4. TOTALDEPTtt .H:
II. CUTTING COLU!OTED: No
II. DOES WELL REPLACE EXISTING WEI.~?
7, STATIOWATERLBVELBelow·TcpctCIIslng;
C\llt.,.l Mew Ttl If c..rto»
No
B. TOP OF CASING Ill II PT.-La1d 6UifBcB"
• CUI'Vr...Ddllllorlldw!llll--llllpl ...... l~ll
t..dir.....-...a&'&QIIe.&CjC MU
I lD(gpm): -METHOD OF TEST:
10., WATI!RZONEB (depltl):
11. CHLORINATION 1P AmGIIIII:
12. CASING:
WELL CONTRACTOR: Rleban:! ShmJO!I!! Qdfl!nq q1 NC
WEU.COM'RACTORCERTIFICATIONII m;t
STATE WELl. CONSTIJCTJON PERMIT II:
DEPTH
"""" TD
ORIWNgbOCil
.P-~·--····
W-·-11-UM-Cifllorm
Wd l'lllciknosa
Ceplb
Fllllll 0 To 18 Fran To
FRill To
13. GROUT:
Cepll1
Fnm 0 To 18
Fran To
14. SCREEN:
Deplll
Fran 18 To 28
Fnm To Fnm. To
15, SANOIGRAIIELPACK:
Doplll
D-O'Woigh!JF~
FL ]"
FL
Fl.
M-
Fl. c""""" ~~
Fl.
Dlamolet" Slcl812a"
Fl. 1"
FL .f.!12
Fl.
-PVC
MCChiXI
Trommle
Mallllllll
PVC
LQCATION SKI!TCH
rs=---~--~~-""'­......,.,_..., __ ,
W. WlloonA ..
Frum 16 To =~28~:FI.Fl. F..., To
Slm
liZ -Sand
18. ReMARKS:
IDOKER!B1C:UJUIY'llW'~VMIIGDHmlUCTI!DIH~WI'NtllNCACIC.W&U.COHST'tUCI10N
.fT~I>J011'1ATAGOPYMTHIBREDDADNdtiiNPROJIDIOTOTWlMLLO.WO
~~-D DIJ~W01
FRCJ'I RSD CAR!JL!t-IAS PHONE NO.. 704 652 1!!678
North Clltolllla-OeQartmenl ol Envlrorunenl and Nllllnl ResaulaB Dlliaio1 of WatGt ~-G.....-er Sadlon
11136 MaiiSIII'IIIceC...IIIr• Aalolgh, NC2711K-1838 Phane(918)1'»-3221
WI!I..L CON8IRUCfiON RecORQ.
wan ldllnlllloatlon 1: MW..Z
3. OAT!DRILL!D: §l1ljg1
4. TOTAL CEP'Tli: ~
!1. CUTTINO COLLI!CTEitl; No
8. COES WiLL REPLACE EXISTING WELL?
7, sTAllO W.ATER L&VEL B--Tq1 o1 Clllll111=
f.luYU .... Tapllf~
NO
8. TOP OF CASING IS .11 FT. Aballe Land Surface' • c:aaktr....._,., ... IIMd ...... IIIDII-. ... .-..."
ls:lu!IIM...,_WIItot&AHGAQICI.tttl
1EI.O (llpm): METHOD OF TeST:
10. WATBRZONSS (d8!llhl:
1f, CHLORINATION Typa: Amount
12. CASING>
WELL CONTRACTOR, Rl;baaf SL'DID!!!J5 Prlping oiNC
WEU. CONTRACTOR CERTIFIOATIONII ,;m;g
STATE WELL CONSTUCTION PERMIT II:
DEPTH
..... To
WaD Thlckr.e:~s
Oc!ltll Prcm 0 To
Fian To
Fran To
13. GROUT:
Oapih
From 0 To
Plan Tc
14. SCREEN:
,,fc;r:' ~-Prom To
Fmm To
15. SAND/GRAVEL PACK:
·Depth
18 Ft.
FL
Fl.
14 R.
FL
f!.5 FL
PL
FL
Frcm 14 To au FL
Pllllll To PL
18. REMARKS:
Dfarnetst orWefShUA. ,.
Malatfal cment Mentlritc
Olameler"
1'
Slzlt
ICZ
BloiSIZo"
,010
Malwlal
PVC
!.QCADPN Sl5§TCH (8'-d_..., _____ _
-atCIIIII'IIIIIp __ ,
Mallled
Tter11mle W. 'NIIIan AYI
M-PVC
IDOHBREBYC~iil1'1R'1MATWSU.WM~EDIJIII~NC8\\IJH1U.HCAC:rc.vmu.CCINII'RUCI'IOH
ar.-.~N&D1'H.t.TAC0P¥0P'ndSIIICCIADHA8111NPIII:Mbi!:I:ITO'n4Wil!.OMIS:I
'.·.
.•,
.,
FROM RSD CAROLINAS PHONE NO. 7B4 662 0678 Jul. 31 2001 1Bl26RM P4
NOIIII Clll'llllna-0epllltmant ~ ElMRIIImenl and Natural R......,_ Olvlslcn ofWa'lllll Quality-~ Sacdon
lfl38Moll SerW:a Center· Raleigh, NC276911-Ifl38 Phona(S19)73~1
WELL CQNSTRUCTION RgCORO
Wellldenllncauon f: MW-3
3. DATE DRIIJ.ED: MilU.
4. TOTAL CEPrn: i1:
S. CUTTING OOU.SCT!C: t!o
II. IJOES WEU. REPI.ACG ElCISnNG WEU..?
7, SiATICWATl!R l.E.Va.Bibor-TopaiCaslng:
CUM VIA&rmTopr:lc:._
No
8. TOPOFCMING IS . Q FT.-La'ldS...,.eoo•
• aasavT'aatulld•t~ettwllrill..,..llltiiCit'*-•...._ll
t.,a,m...,._WIIIIANCAC21:..tiU
.. VII!I.D CIIPIII): METHOC OF TEST:
. 10. WATER ZONES (cleplh):
11. CHLORINATION~
12. CABING:
Coplll
F""" 0 Ta
Fn:m Ta
1'11111 TQ
13. GROUT:
llop1ll
Fn:m g .Ta
1'11111 To
14. SCREEN:
Cepth
F..., ~ Ta
Fn:m TQ
FIIIIR To
18. IIANDIGRAV51. PACK:
~
~ FL
FL
FL
a~ FL
FL
a FL ....
FL
"""" 21 Ta ::38:::FlFL. fR1111 TQ
16. REMARKS:
Amoulll:
WB111'11ckness
Dlar1etur or Welghi/FL
l'
Material
~-!!!!-
01-·
1"
$101 Size •
.010
Material
Sand
Matetfal
PVC
Ut!hod
Tramllllt
Mawlal
~
DEPTH
Frarn. . . To
QBIWNQLM
·-~··
L.OCADON SICEJCH __ .,.. __ 01_ ... _
Reodt, e..,_ ~ fl!fllcwtcl' poOD)
W.Wi&:onA.e
0=
FROM f<SD CAROLINAS PHONE NO. J~l. 31 2001 10:26AM PS
Nollh Caratlne • Deportment al e.wi""'ment and Nlllural Resourc:eo Dlvitlon of W-Qullilly-Groun-Sec11on
11138 Moll Ser.ric:e Cenlor • Raleigh, NC 27a99-1G38 Pllane (919)733-3Zl1
!ELL coN8TRUCJ!o" RECORP
1. Wl!l..l. LOCATION: ai<Gidl tllllta location below)
Neouest Town: · c~ ~~mA~··~-------
a. DATE CRIW!D: lll:ll!!ll1
4. TOTAL DEPTH: !Ill!
8. CUTTING COI.I.ECTED: No
II. 001!8 WILL REPLACE EXISTING Wl!l..l.?
7. STATIC WATER I..E\IEL -~Top at casing:
OJ-'YifAblwTcpaiC1111411)
B. TOP OP CASING IS l1 . PT. A1xM1 Land Surla:e •
• C:MiatT..,....._diW ... Iudlllf'altllolwttt~•...S.:UII·
• ...,..,_..._...'tMNCAC:ZC#I11
III!I..D (SIIIn):
10. WATER ZONI!S (deplh):
11. CHLORINATION T-
12. CASING:
Oeplh
Ftotn a To
F10111 To
From To
13. GROUT:
Daplh
Fnm ~ To
Fnm To
14. SCREeN:
O<lplil
Fran 50 To
Frcm To
Pnm Ta
15. SANDIGRAVEL PACK:
Depth
Fnxn 48 To ,.,., To
16. REMAIIK6:
MEniOD OP TEST:
50 Fl.
Pt.
Ft.
411 Fl.
Ft
60 Fl.
Fl.
Fl.
eo Fl
Ft.
'AmOunt:
Wall Thlcknesa
DIIIIIMiillr or We/gliiiF!. ,.
Malerfal Ceme!J! IBtoi!Dnlla
D!arnaiGr" ,. Slot Sizer
,010
Mafelbl
Sand
Malarial eve
Mellold
T""""'la
Malarial
P1IC
DEPTH QRIUIN(i LO@
-~ n ljllla», ,, '
11.-..o-Ja.-otluuboalloffonn
l!JCADON SKSTQH <m--· .......... -.. _two_
RctaU. fltelftwmap R!lflrluuCIOfnll)
W. Wlaan Aw
I DO HERBY Q&RI"F\'TJW'VW£1.1 WAt CCNIJ'PUC'ISC "ACCORD&Nawmt 1M~-'E!LOQHITRUCTIOH
01NCDAROI. Mea THAT A COPY OPTHIS RIOORD Mo\S B5N IIRCVaDlO l'f!. wm.1o 0¥1t1R
. G"-Jm ~~· D blofi'W'
61WiUfiibf!CONiite+ORORAGEiii.T
NdWCIMI!tDIWIID!toll ....... ~a:lcoar~*ll ....
-·
FROM ' FISD CAROL! NAS PHONE NO. 704 662 11!678 Ju I • 31 2EIIill1 1B: 27AM P6
North Cllltllllla,-0ep811monl ar Env!ranment and Nid\ltal R•aurces DMslcn ol Watar Ollllllty-Grau-r Seatlon
1838 Mal SeNice Center-Relgh. NC 271199o1B38 Phone (918)73~1
WEbL coNSTRUC!loN aecoRo
Wallldomtlloallon Iii: MW4
3. CAT& ORILU!D: 6!1111Q1
4. TOTAL DEPTH: It
S. CIIJTJMG COLLECTED: Ng
S. coa;s WELL REPLACE EXISTING W&LL7
7. STATIC WATER l.SVEiL BeleW-ToP oi CaaJng:
...... YIA&IMTopf! I:UUII)
NO
S. TOP OP CASING IS II FT. Abova LaruiSwtace'
• Glllro~ ............ -.tt ............ ~b
........ ~-·ti4NCMICoiH1•
-.IELD (gpm): METHOD OF TGBT:
10. WATSI ZONI!S (depth):
11. CHLORINATION TYPe: Amaunt.
1Z. QI\GING:
WELL CONmACTOR: Blg!J!K!I Slmmpn!! Qrillng It NC
WELL CONmACTOR CI!RT1PICATIO/IW &
STATE WEll COHSTUCTION PERMIT 1Y.
DEPTH """" ,.. .
DB!UJNG LO[i
.P~~.D 1.:1~
Woll Thlclcnesa
Ce!l1h Fmm a To aa Ft
Fram To Fl
From To Ft
13. GROLIT:
Oaplh
From 0 To 20 FL
Frcm To Fl.
14. SCREEN:
Ceplli
FRIO 22 Tv :rt f~
Fl'llll To FL
Frcm io FL
15. SMIDIGRAVEL PACK:
Depth
Fnw 2D To • S7 Ft.
Fran To FL
18. RJ!MARKB:
Dfom...,. or WOIQhlll'l.
1'
Molen8l
Ceti ISJ II i8erdcn1tB
~· Sid Size•
1" ,g1o
Sl:oe ·. ~-.s·. · Smd
MaletiGI
PVC
Malhcd
· To&iinlo
Ma!tlllal
PVC
lOCADON SKJ!TCH <..__...,_rnun• -MIIIoU! -or ....,. .. P""""""" -)
W.WilaanAw
. ' I
FROM. RSD CAROL! NAS PHONE MO. 704 662 ll678 Jul. 31 21!B1 10:2711M P7
NCI1h carolina· Clopatllll&lll of Envtronmenl and Na!utal Rasauroas Ol>!alon oiWIIII!< aulllitv .<J,.,..,dwalal S41c!fan
1113& MaD 5-Conlet· Raleigh. NC 27BS9-1BSII Phone (919)7$.3221
WELL CONSTRUCTION RECORD
WallldenUIIaallon #: lloiW-5
3. DATE DAiu.&C: §QJQ1
4. TOTAL DEPTH: £
5. CUTTING OOL.L.ECT&D: No
. 8. DOES WELL REPLACE I!XIST!NG WiLL?
7. 8TATIOWATI!Rl.EVI!LB-~TO!IdC8olnir.
tu• ·vr ,.,....Topol ClltiV)
N9
8. TOP OP CASING 16 l! FT. AbcMo Land Sulface • • caNgT~...,._._....,_.,,~~~g~~lrillll•v.IIIIDtl&
...._~...-.'1111111ANCftO;c.Jittl
.1EI.D (gpm): U&THOO OF TEST:
10. WATER ZONES (deplh):
11. CHLORINATION "JP .Amount
12. CASINO:
WEU. CONTRACTOR: Rloha!!! S!mJIIQ!!a QdPing ar NC
WliLI.COI>ITAACTOR CEFmFICATIONjj 3!1!1
STATE WELLCONSTUCTION PERMIT II:
DEPJ!1
. ..
Will l"hlclalau
Doplh
From 0 To
From Ta
From ·To
1:1. GROUT:
Depth
Prom 0 To
From Ta
14. SQAEIIIN:
Doplll
Frcm 21 Ta
From To
F11111 Ta
15. SIINCIGRAVELPACK:
Depth p,... a To
Fnm To
1!1. RI!MARKS:
Cl&melor ..-WelghtiFt. Metallal LQCA.DQN SI<BTCH
ii Fl 1' PVC
Fl
(Shaw_tnd ____ ...,_
~-~---pofto) Fl
Ma!J:rjaJ Melhod
H FL
Fl
Ceml!nl iB<Inla1lls T111111111le W.Wn...A,.
Dilrnolet" Blol&llll" Mal.olfal
~2 Fl. j" .g10 PVC NC41
Ft
Ft
Slzo Maletllll
~~ Fl !Ia Saruf
FL
lac:J~a!ERI'IPYTMTWIILL.,....~IN'OcnpDioHCIWTHlMNCAea:I.WIU.COIIITAUCTICIN
.,.AHDMDS, .u&D1tiAT 4Ct:JI1~ 'rWIIIAEaCAD HIS GID PAOYlD&D 10 'If! WSU.ONIER. ~-JlD~~~o iliii«iOOI 6f em, ea ORxaEliri'
~Uilfttllll!llldta CWAIMOII!IM!Dmii!UI~Roo~• WdCIIrlll
FROM RSD CAROLINAS PHON: NO. 7134 662 la67B Ju I. 31 20B1 1B: 2BR1 PB
lllcrth C1110llna-Doparlmont cfE1111ircnrn1111t and Nawral Rea-D'Msl101 cfW-Cualil)'-Grou-SI!ICIIan
1836 MilD s..,.., Cenlllf-Raleigh. NC 27BS9-1836 Phone [phone]
2.
WELL CONSJRUCI!ON RECORD
wen ldenllflcatlon II: MW.S
3; DATEDRILLED: §I:IQ1
4. TOTAL DEPTH: im
s. CUTTING COI.LECT&D: No
6. 001!11 WILL REPL.Aait l!lCJ8TING W&U.?
7. STAllCWATERLEVELBaiaw•TcpofCaalng: •"""·AbDw T.OIQallav)
No
8. TOP OF CI\SINO IS A FT. Ahale Land Surflloe •
• CIAIIT..._...,.tnwkn::IUW.IIIIglltlllla•Mibrali
' ..aiD--..'IIIItr1M.IDO~.A118
L (JiiLQ (Opm)! METHOD OF TEST:---
1U. WATI!R ZONES (deplh):
11. CHLORINATION 'Tylll!: Amoun~----
12. CASING:
"""" P111111
Prom
13. GROUT:
Fmn
FIOII
14. 8CftEEN:
Fran
Fftm
Fn:rn
0
0
20
lleplh
To
To
T~
Ctillh To
To
Depth To To To
15. SANC/GRAVEL PACK: . Daptll
Pnxn 18 To
"""" To
111. RBIIARI<S:
wan Thk:lmeu
Dl11111alet ar Wlllgh!IFI. Malarial
!!!! Ft. ,. el& FL
Fl.
Moleriol Melhcd
:II Fl.
Fl.
Cemen!IBenlanite T-
o~ame~er • Slot sa• Malerlal
35 FL ==~1·====·~Q1~0~=~PVC~~ ___ FL.
___ Ft.
36 Ft. ___ FL
Slza
lt2
QRIWNGL.OG
Ponnauan. o fpab•
LQCAngN SKE'TqH cso--ancs-.... .... 11-IIIID&IIIe
RDacla, aradlor~ ,.....,._palm).
W. WIIIICIIIAVII
tDOHIIREB'I"i;IRnF\'l*TWIU. WNI~INAI:COJrW.NCiav.rnt 11.' Ht:ICIG1 WiU.~I»t
.r~ANDnc.\'1' AcoP'fOI"'THUU RIIOOADHAII!IIBN PRDYIDJD10THBYCU.CI¥MER
m~·~~~"\... 0 MP'
FROM RSD CAROL I HAS PHONE HO. 71114 662 1!1678 .1u I. 31 2001 1111: 28AM P9
Nllllh Carcllna • Oepllllment d Enllironmant and Natural ~IOVJC8!1 OMslan of Wfllllt Quality· Ghlunllwater S-
18381\AoD SeMca Cenlar • Ralelgll, NC 276&&.11136 Phone [phone]
WELL CONSTRUCT!QN RECORD
Wellldenllllllllllcmll: -.1
bebvJ County. l!!!dafl
3. OATI! DRIU.BD: HUR1
4. TOTAL DEPTH: S1i!
8. cvrnNG COLLECTEl: No
6. DOES WSU.REI'LAC&: EXISTING W!!U.?
7. STATICWATI!R l.IIIIEL Balow• Tcp Ill Casing:
l\JM....-If ....... ~lla.q.
No
a. TOP OP CASING IS II FT. Abele Land Surface •
'"C.WT .......... .,_MafwW...,._ .. '"-IIdl .. ewdaala
-..slo-----1M.fc.w~ .d111
.IELD (gpm): MEITI1000FT!!ST: ---
10, WAT!!R ZONES (doptll):
'IVEl.l. CONTRACTOR:
WELL CONTRACTOR
STATE WELl. rn1~...,n "'"''~'N QJ;AutT 11:
DEP!H CBIWN§'m
. Fannolioo~
11. CHLORINATION Type; MOUnt-----
12. CASING:
From 0
Depth
To 311 Ft. i'rom TO Ft.
Fnrn To Ft.
13. GROUT:
Oeplh
Fran D Tg :18 Ft
From To Ft
14. SCREEN:
Depjh
Fran 311 To 48 Ft
From To Ft,
F...m To FL
18. SANDfGRAVEL PAC!<:
Dop!il
Prcm 211 To 48 FL
Frcrn Ta Ft.
16. REMAAJ(S:
Wolf Thlclcness o~amec... 0< Walghlo'PI. ,.
Malarial
Cement m:!!Jtgnft•
Dlamllllr"
1"
Size
1112
BJotSim"
.010
Moletlal-·LQCA1JON SKETCH
PVC t6110w------... ilara -··'111m'--pane).
Melhod
Tl!!!!mla W.WiaanAw
~ pyc Nc-31
7fWl DXT
NC-110
D=
FROM RSD CAROLINAS PHJNE NO. 704 662 il678 Jul. 31 2001 1B:29AM Pl.B
Noo;th C8rallna • Dlpanment of Envfrcnment and lliatural R_,n:as OMolon ot Wlller Ollallly • GIIIUndWalsr Sedlan
11!38 Mill Setv1ea Canta<. Ralalgh. NC 2761111-1638 Phone (010173U221 .
MLL CONSJRUgT!ON RECOBQ.
Well ldanllllc:allatl 11: MW-8
3, DATE ORIU.SO: §l3:lal1
4. TOTAL PI!F!'H: H
5. Clm'ING COI..L.ECTEC: N9
e. DOES WELL Rl!PLACI! E!XISTING WiiLL?
7. STATIC WATER I.AVSI..Selcw· To» of CUing:·
....... Abowl;'l'ot Of Ollial)
Ng
8. TOP OF CASING IS II FT. Hlf1ol8 Und 8Urf11C8"
• C:.lhlfT..,.......,-..w.-..tf .... IIIIIIIA•-11
..__.rn~·tM JR»CXI.G'Itl
.I!LO (gpm): MI!THOD OFT&ST:
10. WATiiRomNES (deplh):
11. CHLORINATION Tp Amount:
12. CASING:
WELl CONTRACTOR: Bk*hprd Slnunn DrfiDnp « NC
WISLL CONTRACTOR CSRTIFICATIONI illY
STATE! WI!LL CONSl\JCTION PISRMf"r 0;
·-·-~~-... -.. ,...
Will "Thlclcni!IIS
Dfll'lh
Pn:m ~ To
"""" To
l'llll11 To
1S. GROUT:
Doplh
F""" 0 To
Fn:m To
14. SCReEN:
DePh
p""" 4 To
F""" To FrOm To
15. BANOORAVEL PACK:
2 '""" F----
111. III!MARKS:
De!IUI To
To
4 Ft. Fl.
PL
2 Ft.
FL
14 FL
FL
FL
'14 FL Fl
Dl&mo1111' cr Wolghi/Ft.
1"
Mlllaflll
Cem!IJllll!!:!!anlta
DlametBr"
I"
Slm
t/3
SloiSbo"
.010
t.1slarlal . lpCATION SKETCH
PVC (&-----·-... --. .. ---...... )
Method
T[!ID!J!Ie W.WIIwiAW
Matertal
~,;: """''
····'
SENT BY: 10-26-1 :10:01AM :MJD-ATL~TIC ASSOC. ~ 8182508850:# 2/ 5 oua. ; 1U/~b/U1 4:54PLij lecf'ee R705;Psga 2/3 --••"' -11• "' __ .. -...., 1.11~'-II'GI 0
1. WELL U~Apjlllcoal•llol)l Rallldan~al 0 Munlolpal CJ lfti!WIIrtal 0 Agril:ullurlll CJ Mcnllarlnll ;r""
. RIODWI)' D Heal Pump WaiOI: ll!)aallan 0 Ollllt O II Dlllar, 1.111 Ull:
J!, WEU. LDC#,Tl~;(iiiii>W 1kOICII gt "'-laaalir:n !lltOW) -r I ..._.r ....... ~«Ae.cv • ue.. C~Nr~v. .,.le ne,,k . .... . .. ·-.. ·····--·-·-·-····-··-·······---····.········ ..... ---....
DBJlUNOLCG PEPD1 "· ,... 'I'D
0 -3.L
4, DATI! Dl'lll.LSQ f;:jp l · a, TOTALOEP'TH __ ~ -.-G, Clm'INGS CCLL.&CTED VEB NOO ,.., _____ _
7. DOeawa.LREPI.ACEEXISnN WElL7 V&N0~------8, STATIC WATER LEVEL Below T~ 111 CAsinO! FT. .
llU ••• , -. ., Colina I
II, TOP Cl' CASING IS V/J. J'T, Abav-LM!IIi.lirflca'
-rop at ca..._ '*"'lnaledllllllf--..,_ ;,...~n. o ""'-!o In_.,. -•-1iAIICAC~,pHI . . '"'-------
10. VIELO (gp111)1 M:.!l=... METH?D CIF TEST----------:......-
11. WATei\ZONiiS (dapltl): 4/,~ . . -------
2. CHI.OI'IINA-nCIN: Typtl 1/Ai?~lfiZ:.., ___ Arriauill -· ---hll$danal apaca II beadool 1U IIIGII t11 lam! 13. C.\81NB: __ ....., __ ....;, __________ ~
-~-FIWII Q D~:th:aQ Ft.-"./-1-11-~srn m:.
Fran,__ ...... _To-PL---------
1"1'11111 Ta F~---
14, III'IOUTt
. · LQCAI!QN §IC§!CH
. l&'lcrlo ~ llld dllloRoo '"""' • ··-... . Auk• araiiiW INIII ,._ ,IIGINI)
.-"'"" li!J li
~ ~.
POA OI'PIC:B Ulll ~L 'J _,.
aiOJo"""'Car ... ROGN~'RiaWI:I.I. -
Sldlmll ao!GNI• -...wwurCiullllr. -•·--wldllll ;10 daya s.lllllle. _,M'I,I-
FROM RSD CRROL I NAS PHONE NO. 71214 662 il678 Jul. 31 201211 1121:29RM P11
North catalina-Dopas1men1 Ill Enlllranmant and Nalural Rescurces Oivialon Ill w.ur Quality-GrDJIIdwlior SIIQian
1838 Mall Ser.ic&Can!er-Raleigh, NC 2761$-1838 Pl111111(919)7»322t
WELLcoNSTRUcnoN BECORD
Walllllllrdlllcatlon 1: Mw-t
WELL CCNTRACI'OR: Bk:hl!r!l !llm!!!O!!!J Drpgng It NG
WELL CONTRACTOR CERTIFICAllONf am
STAT)! WELL CDNSTUCTION PERMIT t:
1. W&LL L.IJCATION: (Sr-lllr8lch of lha lacallan belOw) ~IT...,. Mcywbk . Counly. ,lradei=:.,_I--:----S!!!!!J MaD 81n!et
DEPTH
Fnm . 'J't ..
PRIIUIG bOO
.!~~D.~.
3. DATEORILLI!C: l'l/allQ1
4. ToTAL !li!F'TH: .ill
~· CUTTING COWOOTI!D: · No
, IL DOS Wl!U. RI!PlAC& liXISTlNG weLL?
7. STATIC WATI!R LE\11!1. BoillloY • Top of Clllllng:
tuii•VIfAIDWTDpcrt c.tiQI
No
IL TOP OF CASING lS g PT. Allava Lind Sudaoo • ·-·---loot-·--·-~ . . ··-~llllb1a.\MCAC2C.D111
. . •• I'IET.D (glm): M&lHOO 01' TEST:
'· 10. WATaRZONES (deplll):.
11. CHI.OAIIIIATION 'fWr.
12. CAS!NG:
Depth
Fram o. To· 5 Ft. From To Ft. Frun ·To Ft.
13. GRCUl':
Dlplh
Fnill 0 To i! Ft. Frun To Ft.
14. SCRBEN:
Deplll
Fnm s To ]li Ft.
'""' To Ft.
Fnm To Ft.
•. 15. SANDIGRAVELPACIC:
Deplh
FRlm 3 To ::]~5=Fl, Fnm To Fl
11!. REMARKS:
Amount:
Wal Thlolcnoaa
D~ orWolgh!IFI.
1'
Malariol c......r-
Dl-·
1"
SiZB
112
Slat Sa'
&lQ
Material
Sand
Mlllerlal
Pile
LOCAIIQN S!SEftiH (Showd_ .... _ ...... __ _ _., ___ polntal
l\lelhod
T"""mfa W.WII1111Avo
Materilll
PVC
FRil'1 RSD CAROLINAS PHJNE NO. 704 662 0678
North C"""!na. Ceparlrnionl cl EIMionment and Nllural Raoaurces Clvislon afWiJ!ttr tluallly • C1lll>UIICt.'llllllr sectltln
1e3e Mall Service Cenler • Raleigh, NC l!761111-1638 Phone [phone]
WE!.I. CONSTRUCTION R!!CORD
Wellldellllflt:allan~t~ MW-1a
3. DA~ DAILLEO: l!I.1IQ1
4. TOTALI:I&PTH: ·2!%
· 5. CUTTING COLU!CTEEI: No
B. DOES wa.L REPlACE I!XISTING WEI.L?
7. STATI~WATER IB\IIiL Solaw• TCIII clcaal~il:
(Lilt'wi"I,._Te~p•rc.l9
B. TOP OF CASING IS II FT. AbDIIII Land SUr1'llae • . ar.ti!Q,_._,.II/ol._... .... .,.. .. lloil ............... "
. ........ ............. NI:SAO~JJI11
' ol!lD (Rpm): ~ODOF~: ___ _
ID. WAT&R ZONES ('*'Pihl:
weLL. CONTRAeTOR: RJctwd Srmmp Dt11Jtm qt NC
Wl!ll CON"IRACTOR CERTIFICATIONII .i!l!!!!J
8TATEWEU.CONSTUCTION PERMIT I:
11. CHLORJNATIONfypt; Amalint. ----
12. CA81N&.
Oapth
Prcm 0 To 10 Fl
From . To Fl
Prom Ta Fl
13. GROOT;
Ceplh
Pnxn 2 To 8 FL
Fnrn Ta Fl.
1-4. SCRI!I!N:
Depdl
Fnxn 10 Ta l!2 Fl. ,...., To Fl.
Fnrn To Fl
15. SANCIIGRAIII!LPACIC:
Deplh Prcm a To 20 Ft. Fnxn Ta Fl
111. R!MARI<S:
Wall Thloknets
Dlllllleler crWtlghUPI.
1"
Mlllerill
§;""""" 11!-i!e
Dllmetor'
1"
Size
tf2
!lkj Size"
.010
Mal!!rlol
PVC
Method
In~nau!o
Mablrlill f!l!C
LOCATJQN Smt;H
(llnow-OOCid.......,...,ll-boolltala -01-.. p-polnlo)
W.WDianA ..
NC41
1 ao HBIII"'CIM'Ftlh'T \1\UU. Wo\5 c::cwrmwcmm 1M 14': ::rm*tHC:I Will '* NCW;aa, WIB.I. CClNI'J'RUOnC»
STANCMDI. HCI'TMAT 4 t:Gfl'tOP'1MIRICDIUI MAl liEN IIRCMDBJ TQTHS'M!LL.QWUll
~~~-0 71.!2'01 bAil:
FROM· R5D CAROLINAS PHONE NO. 704 662 B678 . .Tul. 31 21!01 10!3i!AM Pl3
Nlll1h Canllina· Department c1 """""""""" and NllluruJ Rescu.-DMafan of w-QuOoty • Grcundwaler-1838 Mill Str111ce Cemer. Raleigh, NO 27~ 1635 PIIOne [phone] · •
Wgll. CON8!BIJCDON RECORD
Wallldaft1lllci&lon t; MW-11
a.
3. DAT_E DRJLL&D: §WIQ1
4 •. TOTAL DEPTH: :4!1:
~ CUTTING COLLECTED:. No
6. DOES WELL REPLACS EOOBTING WELL~
7. STATIC WATER I..EV!\.Below• TCil al'ColllfnQ:
(UII"tt-IMaw!Tapaf~
Iredell
Np
L TOI' OF CA&INa IS Jl FT. AbcMI L$1C! Surfaaa •
'QMtvT---IIIIarbdnr..W.aitaftlllpi..-.IVftalt ,_.,_..,IIIIIIWIIII.D111
., .oil.D (gpm): ME't~OPTSST: ---
WEll CONTRACTC:'R! Richard SJmrrtgM QriiUng oENC
WEU.CONTRACTORCERTIFICATIONtl &
STATE WELLCON$TIJC'T10N PERMIT II:
DEFTH QRI!J..!NG LQG
. Plan ... lb ......... P-~-
10:. WATE!R ZONES (dep!ltt,
11, CHL.OAINATION Tp:
12. CASING:
"Aillcuri: _. __ _ ·--~~·---"'-
Fnm g 0~
F.tan To
Ftall To
IS. GROun
Dep!h "-0 To
Fran To
14. SCREEN! ;2 Depltl
Fnm To
Ftall To
1"11111 To
15. SANOIGRAVEL PACK:
Doi>lh Ftom i!8 To
1'1111\ To
lB. Rl!lMRKe:
wau Th!ololau DfBrnot!or 01 Wolghi/PI.
3R Ft. ,.
Ft. F~
"'-'"' 2B FL Cement Qi!entor'lfta
FL
Cf4-01-· SIOIB!ra" A( FL
FL !" .010
Pl.
45 FL ___ FL
-PVC
Molhad
T11111m!!
Mllleria!
PVC
'006.mt!5 WOH ----~~~-~~--­Roodo, .,...., """'-11011111)
W.WIIoon,..
I DOH1iR1Dn'08RT1P\'1W.T MU. w-.;CQNIT'A:.ICriD IN ACCORDAHCB WITH IM.IlCAD 1C. VdU.ICCINSTJUJCmOH
ITANDAADS.,AHDTHAf4CIFtCV'tMIREI:IOACHA&ISRHPRIMliD1UMMLLIM1GR
~·~~r~D li atXiiiNT Ndotidt~CrdM!I"'fMI ..... ~.,..,...MI_,.CD*duasr,
·.
D=
SENT BY: 10-26-1 ; 10: 02AM ;MID-ATLANTIC ASSOC • .., 9152609950 ;# 3/ 5 ,.,,. ; · IU/211/01 415SPM;IP!FM N706jP&ge·a,.a .. .,..,'" -~ t -------.. , ... ~tiVI G
1, WELL Ulli (ChoakAIJpllllalio loJO; Flealder\11~ 0 Nllnlc/pal 0 lnchlalrlal C] Agrir:u(bnl D t.IGrdlaling e""
Aeoiiii•J\1 Cl Held Pump Willar ln,J..Uon CJ Olhar t:J If QUiel', Ull Uw.
z. weu. 1...3Uan .....,.l
DIPJH
• CHLORINAllON: iwe ,._i...,tr..,.... ---IIITPUIII ---II llfdlllalllf apaca llllllldlld -IMR Gf ICIIII
11, c;ASINCll ----------------
WollT/1-Fialn....:;.tJ_o;.:~Fl D)l!lar £%tl.S.
Flbm TD FL---
FIDm To-F•---
1 4, GROU'r:
69CATI9N Bmcl:! ca....,.._. • .,.. • .._,,.,..~eut_ a'*
....... .,.._....,. ,., ... _ palftb)
·------
SENT BY:
Mt. DY: MC.,;&.I.J. tsru Lm'I'D 10-26-1 ll0:02AM lMID-ATL~IC ASSOC. ~ 5152508550:# 4/ 5 ·~' ... , __ , __ -·.--·· .. ··--. -
Hl>niiCanailna•~-'allillwfNIIIMOI...:IIIhillni""""'-•OMiioaiiiWIWCWJIIr•........_ .. , ....... 1fllllllll8ttila Conlllr•llllaio._, N.C. ::17Gt-11t" Pwu• (tll1J7BWII21
.JELL CCNSTRUC"f''ON RECORD WELL CONTRACTOR: f.ce~\\ fDA:fJ4t!d;p..J.t:fi4p
WELL CGftriiAcnlfl Cllt'ni'ICA11CIN at __ _ _ 'f 4/ {J 7 0 \ 'B t'\\IJ-l l.S lli'A'M Wa.&. CONITRUCTICIN IIIRIOI'IJ .
Munlolpal CJ lnduoldal CJ Aerlaullullll 0 Maoliollna Er"'
Ollllr (J II Olllllf, Uti Ue-:
DBILUNGLOG
F-Ya
12 -;z,.c
DSf'IH
.... Cloft..ORJNATION: . Type .. A~ot.f.ll40c::---Am•~••---"llldlllollll.,....ll no~Ad uu bialc"oJ t-13.C~N~ -----------------------------.
w.J1 'lllldoooN
Pram e'J D:lh I@ FL a;.'"' mr· lte
P!D'"'---To--Fl.---
Ftam To rl.---
14,13ROUT:
Pram Q ~=P"k; FL Gttfn" l:rl
F111111 --To FL ---------16,8CAEEN:
O..pdl Dlamolltr Slot SID ft'UU8!111
Fnllll JL To .J.S:.. PI _j__ ln. &!J1l. ln. flit(!..
Pliom -To-f'l, __ Jn, -kt. ----Ftam-To_R._ ln. _ln. ___ _
18. BAHCIIGRAVEI. P.ACI<:
FIIV!I 2J 0-.:~h 2.S" Fj. Jli_ swl
P'111111 To l't. 17. REMARKS: L;idi!!Wi:f7""'Cio::--,"T'J/y, .,,
""'Y 1JS ..
I DO HSROV~11FY'll4ATTWISW61.1. W.lll CON&TRUI:l'IID i11AcCC2fiD4NCEWITH t6A NCACIICI, WELL
CCNiiTRIJOTICIN STANDAIIOS. ANC"'I'I<AT A CCPY 01'11-118 A!CI?[III HABIII!IIN l'fiCIYIDIIg TO THI! WilLI. CIWHI!II..
1'01\0P~f!UBI!ONi,; t.Ooi"'itt" ;4.,0 ·O'f-1"1-0I
"""""'" ... Nil lUI• QO' -CCNIITRUCTINI: Tl4li w&l.&. .. lllol!l -.... .-~~Wn" It Dioobfonal-r Clllllill)l, ;....,.,., .....,lllilhfn :10 clay a ·
10-26-;.! j~0:02AM :MID-AT4\NI:.II; ASSOC . .., ·--
QR!LLING LQSJ
filii! , •
. if' -z. -a..
"· '· -./ &. CUTTINtiS YIIS!J,6 NoD 1. ooas wa.L FIEIPLA.CEi EXI8TING wSLL' Vis D tjO(B"':-..: ____ _
8. STATICWA'T&RLlVEL.I!I•~TapafCulng: JJJl:_FT.
· . · 1\111'•' U -TOIIII CU11111) 8. TOP OF CASING Ill MA-FT. Ab-1,81111 Su,_. . -------
"''CIP allllllno-I•IIIIIIVr """"'lud•urt-IIIIIIIIUI Wlllii'Min a... ______ __;_ -.-...-NCACz;.ma . .
10, YIELD(gpm): NtC.. M~DOFTEST-·-----------
11, WATERZONES(dopll'l):..~oiJit~L----------------
81Jl25.!J8850 ;# 5/ 5
•• CHLORINATION: TV~~• PA . Ama\1111 ---lllllldlllonol op~~~~la "'lllllod -bok of lam 13. CASING: ____ ....; __________ _
"""'""---Ta-,-Fr---
f~Qjft To-PL~--
14, QI:IOLm
Depltl
From Q To ..:L-FI.
From __ To Pt._...;. ___ ----
1!. SCRI!I!N:
Depltl . OllllNIIBt Slat SID
Fan ..::t-To ...2.:.1-Ft -'-ln. JIJil.. Jn.
litem _Ta-FL-ln.--'"·----
F"""-Ta_FL_ ln. -ln.---
111. BANCfGMVS. PACK:
From o 0f:Q a J'!.J'£ slw'
Pram Ta I'L .,.....---. ~~""""-=..---1?. R&14AR!CS: j, •lfiiyJ t-_; 3 :;:, ?".
MWII
U5
I C10 HI!III!IS'I' CI!AIIPV ntATTHIB\118LL WAll CQIIIITRucrEIIINAccQIIDAI'IC!wmt IliA NCADI!C. WILL
CCIN8'11'1\JOTIGN ITIINDAACB, AH0 TWIT A COP"( OF "TillS JIIECQIID HAl II miN PRCVICEC 10 THI WI!U. CWNISR.
POR OI'I'ICE USa ONLY --
,,. .. .
IIW.I JIIY, I-
lENT BY: 3-21-2 ; 1:12PM ;MID-ATLANTIC ASSOC. ~
Nl>rib CatD&no • Dep•rlmom af Envlranrnent; Haallh, and Natural Reoaurcos
DMaian at invt~en""'ntal M•n"'lemont-Go-aundwa~er s .. &an
P.O. Bax 285:15 • Aalol;h, N.C, 278%8·0535 • '
Phane(B19)'13S-aUI
W&U. CONSTRUCTION RECORD
(A .. d, ClarmNiUiy,or 8..-uian owl L.allla~ DEPTH
!. OWNER-·------------------Frv"' "lb ADORE~------~--~--~----------------~Q~~1tJ~~'---­IS...I Ill' Aolllo Na~
Clt;ar T-. s .. ~o Zip Coda
I. DATE DRILI.!O ~:1. -a f:1''L USE OF WE. l.L lr'O"if•r
I, TOTAL OEPTH='U~-~-~""!"=~
'· oumNGs COLI.EOTED ves (;?I NoD . ~. DOES WEU AEP,LACE EXISTINGW&u.? VES 0 NOI2! r. S1 A TIC IJI!ATER t.E\IEL Below •Top ol Casln;; FT.
. (Lila "•'II.Abwo Top ot culnal
I, TOI' OF CASINO IS .S FT. ~d SurfaGa•
'COOIIII Tlrmlllai!MIIIIIarllol-... dauJI-tofi;.:ilntno OV•I..-Ia ......... ---------
llllliDD!donao"lllteAJ(CAC2Q .,,. •
9, VIELD (gprn); METHOD OF TEST:...· -----------------------
10. WATER ZONES (Cieplll):---------------------------------
9192509550;# 2/ 9
pRILLING .LPG
For11111dtn llwn~l'!l!m ...,,, silt
11. CHLORINATION: Type --------Arncunl-----II oddhlonal -· I• ,...,~ UP buk Dl farm·
12. CASING: ------------=----
Depth 01;-io'
From 17 Ta ,S FLoroli{!~-
From·---Ta---FI.---
FrCim To Ft.~. --
13. GROUT;.
Wall 'l11leknels or Wolgnlll'l. . ll.,.rlld _seu 110 PV4:
From ps:
Frll171 23
14, SCRElEN:
Deplll
To 23
To .S
~~~)J _Me_lh_c_d_
· Daplh OJam:tar Slot Size Malarial
From ~Ta..A1....Ft~ ln. ~ln. PVC..
Fiom-Ta_Ft.-ln. -'"·----From -1'a __ Ft.-In, __ ln.----
1 S. BANDIQRAIIEL PACK:
Depltt Size
Frcm 4 4-Tc .IS Ft. • #
Frcm To · Ft. ___ -------
LOCATIQN SIC§ICH
(Sh-dlrOGiiOn 111d dlotanoo !TDm Dll .. ot IWO 81alo
Raada, ar ather map releronce ptlnt•l
16. REMARKS: ___________________ ......uL...-. __ _._ _______ ----
I CO HEREBY CERTIFY THAT THiS WELL WAS CONSTRUCTI!.O IN ACCOFICANCG WITH I $.to "'CAC '2.C, 'fii!U.
CONST.RUCnON STANDARDS, AND THAT A COPY OF THIS I'IECORO HAS BEEN PROVI050 TO THE WELL OWNE!t
.OW•\ RE" Ml 'IGENI' OATi
MllniAI !111\&111'"0:11 111d co~y to wei •-•
ATTACHMENT C
MONITORING WELL
ABANDONMENT RECORDS
MP?;~JMVi.T!~
En~inaring &: Environmtnltll SolulionJ
WELL ABANDONMENT BECOBD
North Cmulino Deportment of Environment ond Notund Reso""""'" Division of Water Quolity
WELLCONTRACTORCERTIFICATri~O~N~#:3:~:9===============--------------,
I. WELL CONTRACfOR:
Gary Fischer
Well CcntractDr (Individual) Nama
Mld-Atlantlc Associates, Inc.
Well C011troc10r Company Nama
STREET ADDRESS 409 Rogers View Court
Raleigh NC 27610
CltyorTown 81010 ZlpCodc
<!!!L..J -250-9918
AmL coda-PhcmD number
2. WELL INFORMATION:
SITE WELL W # Ofapplicobla)..;;tlfN=--'1---------
STATE WELL PERMIT f (lroppUcoblo).:.;NA::...:_ ______ _
COUNTY WELL PERMIT# Ofoppllcoblo)c.:.NA::..:.. _____ _
DWQorOTHI!RPERMrT#OfoppUcoblo)"-NA;;....:_ _____ _
WELL USE (Cbcck appUcoblo 1110): iZI Maallorlng 0 Ruldondal
0 Munlclpai/PobUc 0 lodUJtriiii!CammarciDI 0 Agrlcallorol
0 Recovery 0 ln)ccUoo 0 lrrtgoUun
001bor(IIIIU30) ___________ _
l. WELL LOCATION:
COUNTY iredell QUADRANGLE NAME-------
~TTOWN:..;;M~oo~res~vi~lle~--------
(SIII:CI/Road N-Numhor, Comaumlty, Sobdlvlllaa. Lol N~. Paml, Zip C.dol
TOPOGRAPHIC I LAND SETI'INO:
IZi Slope 0 Volloy 0 Plat 0 Rldp 0 Othorc ______ _
(Cbeck appraprio:o sattlnJI)
LATITUDE ~ 35.573:::3:..:1'-----
LONOmJDB W 80.822:.:.12=6:.._ __
LoWade/loagltoda 10urce: iZI GPS 0 Topugrupblc map
(LPCt~don uf•vell must b• •lmwn on a USGS IOpo map and
•n..Juo/ID tht.form l{nol win& GPS.)
4D. FACILITY· Tha IWD&I ald. biDiaca wben dlo weD Is lacmaL Comploto.ca aud4b.
(Ira raldcntiaJ waU.Ikfp -4a; complcta lib. won owm:r bdbrmadonooly.)
I'ACWTY W #Ofopplloubla) NA
NAME OF FACI!JIY Moores.:.v:::,Ji;-lle-,M:-:;;;llls-------
STREBT ADDRESS 476 South Main Street
Mooresville NC 28115
CltyorTowa SIOio ZlpCoda
4b. CONTACT PERSON/WBLL OWNER:
NAME Cherokae Investment Services, Inc.
STREBT ADDRESS 111 E Hargett Street, Suite 300
1'-.o.lei h l'\I.C:. Z. 7CDOI
s. WELLDETAILS:
a. Tolol Dcplh: 28 ft. Dlamclcr: 1 111.
b. Wotcr LIM:I (Balow MCDiurfDB PolnQ: 22.71 ft.
MCD1urlns point II 0 n. oloawlond lllrlbco.
CASING: Lonsth Dbunarcr
a. Caslos Depth ormiiWII):
b. Casing Removed:
-,;.18~_n. 1 lu. ...:_ __ n. ,-lu.
7. DISINilECTION: _;_N,_A,__ ___ _
(AmOIInl of&S%-75% colclum ~lo UICd)
8. SBAUNG MATERIAL!
Nn•Ccmcnt
Como,.:r;20::....__1b.
Wolor .0 pl.
QqgtanUg
BODioDIIO 0. 5 lb.
Typo: IZi Sluny 0Pollala
Wntor pl.
!1llw:.
Sgpd Cement
Ceman;;tO:_ __ Ib.
w ..... o pl.
T7Pa molorloi..:N.=A..:_ ________ _
Amouot.:.NA=----------
t. EXPLAIN MBTHOD OF EMPLACEMENT OF MATERIAL!
Surface Pour Mathgd
10. WELL DIAGRAM: Draw a daiollod lllcctcb of tho waU ao tho back or this
lbrm sbowlos to1o1 depth, dopth Olld clbuuolor or......, Ofaoy) I'OIIIIIIolaa
lo tbo wol~ JPBV•I lolorYDI.Iolcmlllorcasloa po~ Olld depths IOd
oypcs or fiiiiiiOicriDIIIIICd.
SICNATUR£ OJI' PRIVATE WELL OWNER ABANDONING TBB WELL DATE
(1111 prlnso well aWDarmus& be 1111 ladlYidalalwbD IZI3I!HIIIll.llhm:laas b!ar'bl:rradd=d!d weD
lo"""""""' wllh lOA NCAC 2C .Dill.)
Gary Fischer
PRINI'EII NAME OP PERBON ABANDONING THE WELL
Submit a cap)' to the owner aad the orlglnal to the Divflloa of Water Quality wlthla 30 doyt. FonoOW.!D
Rev.~& Attallnf'armotloa Managemeat.1617 MaU Sa"lca Center-Ralefuha, NC 276S)9..16171 Pboaa No. ('19) 733-7015 ut 568.
. ··-iiiDILW
oXII NDt CICICIR1127.00
CloD ' 01-112717
awa ICb 1.1
showing IolBI depth, depth and diamoter of
Bcntellll remaining in thewoll, pvel interval,
intervals of casing porforatiDDS, and deptbs and types
of fillllllllerials used. ff.. i7-) tnW-: I< '"fJ!-.J./.-/
;u'
WELL ABANDONMENT BECORQ
North Carolina DepnrtmontofEnvlronment and Naturul Rem....,.. Div!Jinn of Water Quality
WELLCONTRACTORCERT~lCATrl~O~N~#:3:33:9===============--------------,
I. WELL CONTRACfORl
Gary Fischer
Woll Con ... tor (lndlvldnnl) Nome
Mld-AUanUc Aasocletes, Inc.
Well c .. ...,., Company Nama
STREET ADDRESS 409 Rogers View Court
Raleigh NC 27610
CJty or Town SlDIO
~-250.9918
An:o cndc-Pbnna numbl:r
Z. WELL INFORMATION:
Zip Coda
SITE WELL 1D N 0fappllcabla),.:;M;:;W:.:..::·2,_ _______ _
STATBWELLPERMITf(lfappUcahlc).:.NA::...:.. _______ _
COUNTY WELL PERMIT# (lfappllcabla,~.:) Nc.::Ac:.... _____ _
DWQ ar OTHER PERMIT I OfappUcahlal'J.:NAC::.:'-------
WELL USE (O.cck appUcahla usa): Ill Moaltarloa 0 lbsldantW
D MunldpaVPubUc 0 lndualrloi/Conunarcllll 0 Agrl<ollnral
D ReCOftry 0 lojcdlon 0 lrrlgotloo
OOth.,.Oistuao) ____________ _
3. WELL LOCATION:
COUNTY lredall QUADRANGLE NAME
NSARESTTOWN: Mooresville ------
(S&rcc:IIRGad Name, Numbu, Comanmlly, Subdlvb:laa. Lot No.. Pan:ol. Zip Coda)
TOPOGRAPHIC I LAND SliTTING:
IZJSicpo 0Volloy OFbU 0Rldgo00ihorc _____ __
(O.ack appmprlalo 1eii!Dg)
LArrrtiDE N 35.574..:..;1:.;:.9 __
LONGrrtiDE W 80.82:0:.;:.9 ____ _
LaUtude/loouJtuduoun:lll Ill GPS OTopoiJI'IIpblc IIIIIP
(Locollon ofwo/1 m1111 bo rhown ono USGS IDpo mop and
11tUrt:lu:tl Ia th& farm f/ ntJI uti'Yl OPs.)
411. FACILITY -lba aama arlba bu:siAcu wbaa cba WIIIU Is kx:Gicd. Complcta -ta ISII4b.
(Uo.........a.l..U,stlp4o;"""'""4b,wdlo"""lalbnnodoallllly.J
FACILITY m BOfappUcahla) NA NAMEOFFACn.rrvMoore~sv";llf,o:le~M=IIIs:-------
STREET ADDRESS 476 South Meln Street
Mooresville NC 28115
City or Town Zip Coda
4b. CONTACf PERSON/WELL OWNERl
NAME Cherokee Investment Services, Inc.
STREET ADDRESS 111 E Hargett Street1 Suite 300
"PPo.lei h NC. cil'll#OI
8. WELLDETAILS:
o. Totol Dcptln 31.5 ft. Dlamctcr: 1 Ia.
b. Wa:cr Lovol (Below Mcoourtog Point): 19.97 ft.
M.......,a point Ia 0 ft. abowlond ourfbcc.
a. CASING: L<ogth Dl-
.. Cmoloa Depth or1c:oow11~ 18.5 ft. 1 ln.
b. Cnnlos RcmoYCd: ft. ,-ln.
1. DISINFECTION• NA
(Amount af 6.1%-75% colalum bypacblorlto uacd)
B. SEALING MATERIAL:
tll~:~~l~'"-al Sgpd Canrnt
Ccmca~ 10 lb. Ccma:tO lb.
Wator gol. WatcrU gol.
llmdBDIIB
llcntoolto 0.6 lb.
Type: Ill Sluny 0PcUoll
Willer gol.
Wl1lr.
T»!OIIIolorlol NA
Amount NA
'· EXPLAIN ME1110D OF EMPLACEMENT OF MATERIAL:
S1Jrface Pour Method
10. WELL DIAGRAM: Dmw a dclollcd mll:b nfthowo:llon thobackafthiJ
lbnn obowlog lolol depth, dopth ODd dlomctor or ....... Of any) mnolnloa
In tho wol~ IP'Ivd lotorvol, lntorvolo of COlin& pcrforollana, ODd dcptho and
'»'<" ofDU mall:rialousod.
lL DATE WELL ABANDONED ..=9:,:/31::.;0::9~------
SIGNA TORE Dr PRIVATB WILL OWNER ABANDONING THE WELL DATI:
('Jbo prima waU awucr must ba qiii!Mdud who IIIIIIUJIIll.lllllmdolll blllbar Rlfdcadal wall
Ia ........me.. with UA NCAC 2C .Dill.)
Gary Fischer
PRINTED NAME DB PERSON ABANDONING TU£ WELL
Submlt a copy to tho owner ud tho original to tbo Dlvbloa atWater Quality wlthln 30 daya.
Atta: laConnatloa Management. 1517 MQQ Stnlce Center-Ralclgb, NC 276gt.Jfil7, Pboaa No. [phone] ut 558.
well showing lola) depth, depth and diouneter of
acroona n:maining in the well, gravel interval,
interval& of caaingperfomtioD&, and dep~ and types
offill materia.Jsused. mw-2-( f'1/e.:JJ)
I,, · . . lie¢ tene.L-
Ct;Sjn'l---1/
o-t8s' ~-3/.r'
~-(HZ) ~tAtrl
I ~· /lt.S1•3/.S'1
I" .
) Ut:.t:--
/13.!'-31.~' ..
vs'J ... . ·
~ . : . . .' .. ··
WELL ABANDONMENT RECORD
North Carolina Department ofBnvimnment and Natural Roaoun:es-Divbdon of Water Quulity
WELLOONTRACTORCERTDnCATI~O~N~f=33=3=9===============--------------,
I. WELL CONTRACTORI
Gary Fischer
WaU Canlraclor (lndivlduul) Nama
Mid-Atlantic Associates, Inc.
WcU CanlriiCIOr Compony Nama
STREET ADDRESS 409 Rogers Vlaw Court
Raleigh NC 27610
City or Town Slate Zip Code
c.!!!LJ. 250-9918
An:a code· Phone number
2. WELL INFORMATION:
SITE WELL 1D I oraPJ!IIc:abla).::M::.,:W'-=-'-3~--------
STATE WELL PERMIT I (lrappllcnbla)o.!:N:!.A!.-_____ _
COUNTY WELL PERMIT I (lrappUcnblaoJel N"A'-'-------
DWQ arOTHER PERMIT I (lrappUC11blc)c.:.N::.A.:...... _____ _
WELL USE (Check appllcnbla uso): Ill Monitoring
D Mualelpal/PubUe C]ladultrloliCommerdal
D Rocov.,Y D lnjoctlan D lrrlgollan
D Ruldenllal
D Agrlculturol
DOtllcrOiatusa) ____________ _
3. WELL LOCATION:
COUNTY fradall QUADRANGLE NAME ___ _
NwuumTTOWN:~M~o~o~ras~~~ll=a ________ _
(SOoociiiiDod-Numloar. CommomiiY. Bul>dlvisloo. Lot No. Parcot. Zip Codo)
TOPOORAPHIC I LAND SI!'ITINO:
IZJStapo DVallay DFiat 0Ridp00t11cr _____ _
(Check approprlato 1atdnB)
LATITUDE N 35.57::.:57c...:4 __ _
LONOmJDE W 80.81:..;;9"'-11.:...,_ __ _
Latllude/loagltodOioorcm Ill GPS DTopogropblc map
{£ocatlon r:(1t~•ll mmt b• 11Knvn on" USGS 1Dpr1 map and
alttlcMtl hJ lhbfarm V not ruing OPSJ
4a. FACILITY·11uo aamo artbo ba11aoA ...... lbo waD~ Jacotod. C...,.latlo 4o aod4~ oro ........... wall. .... 4oo; _ .... 4b, waD awncrlnllonmlfao """·)
FACILITY 1D tarappllcabJc).:.N:;A:;....,=-------
NAMEOFFACn.rrYMDorasvllle Mills
STREET ADDRESS 476 South Main Strset
Moorasvllle NC 28115
City or Town Slate Zip Coda
4b. CONTACT PERSON/WELL OWNERI
NAME Cherokee Investment Services, Inc.
STREET ADDRESS 111 E Hargett Slrae~ Suite 300
'R<~.lGi h Nc cii'HoOI
a. WELL DETAILS!
o. Total Dapt111 38 ft. Dlanwer: 1 ln.
b. Watcrl.ovoi(BalowMcaouriqPollltt. 29.70 ft.
Meuurlns point Ia 0 llabovalaad llllrlhcc.
6. CASING• Diameter
a. eoa1118 Depth (U:known): .:;2;::;3.---11. 1 fa.
b. Coallls Removed: 0.6 11. ,---1a.
7. DJSJNF&CTION1 .o.NA;::.:. ____ _
(Amount of&S%-7.1% calcium bypacblorl!O UBcdj
B. SEALING MATERIAL:
'·
Nco• Crm•n*
Ccmco·~'l" 2~.0=1b. Watcr..l:.D pl.
Bcnlgnltg
Bcataai!O 0 • 5 lb.
Type: Ill Sluny 0Pallabo
Water sal
WI!!!.
Sgnd Cemc:ot
Typo malmlai.:.N::.A.:_ _______ _
~~NA~----------------
EXPLAIN METHOD OF EMPLAC&MIINT Otr MATERIALI
S••rfaca pour Method
10. WELL DIAGRAM: Dmw a clclllllcd ..... b ofti1a well on ti1a back oftbll
form abawiq 10ta1 dcptll, daptll ood diamator or......,. (U'oay) mnafaiD&
Ill t11a well, wovaJ latcml, lnlorvalo or casfaa pcrlbmtlaaa, ood daptbl ood
types orml malorlabOicd.
9/3/09
BIONo\TtiRE or PRIVo\TE WELL OWNER o\BANDONJND THE WELL Do\TE
(llulpdw~owaU ...... -ba aaladMdudwba Dmmlllb<aboodauliblbcr..........WwaU
ba .....,._ wldo t!A NCAC 2C .0113.)
Gary Fischer
PIIINTED No\MB or PERSON ABANDONINC THE W&LL
Submit a copy Ia the awaer and the arlglcaltotbe DIYIJiaa aCWater Qaollty wltbla 30 dayt.
Altai laCarmnllao Mnnagam~a~ 1617 Moll Sorvlco Ceater -RabiJib,NC 276tll-1617, PboaaNo. (tit) 733-7015 ut568.
weD sbowiDg total deplh, deptb and diameter of
screens remaining in lbe well, gravel interval,
intorvals of casing perf'matioo!, and dq>tbs end types
of fill materlals used. "!!:f.:;:) (/;r 11:)
i' e~£ ~1
{..A S/lli ---4 nepJ~ t.emeJ..
0-'23' p•38'
'. / ~·#J}St~AI
. . . ~'-311 .
. ,
WELL ABANDONMENT BECQRD
North Carolina Department ofEnvironmeot and Natural Resources· Dlvfaion of Water Quality
WELLCONTRACTORCERTDnCATrl~O~N~#=3=33=9==============:--------------,
I. WIILL CONTRACI"OR.:
Gary Ascher
Well CoaOBCIOr (llldlvlduaQ Namo
Mld-AUantlc Assoclatas, Inc.
Well CaulnlcterCampallyNBJDO
STREIIT ADDRESS 409 Rogers Vlaw Court
Raleigh NC 27610
City or Town Stnto Zip Coda
t!!!!...J . 250-9916
Area coda • Pboua lllllllbcr
:Z. WIILL INFORMATION:
SITE WEU.ID R OCappllcable)•..::M::;W:..:..:·5:;_ _______ _
STATE WELL PERMIT f (lfappUCIIble).c:NA:..!...-"-~--"----,
CoUNTY WELL PBRMIT# (i£appllcablel•cN.::A~-----­
DWQarOTHERPBRM1T8Qfappllcab~~NA~------­
WIIU. USE (Cheuk applicable usa): Ill Moaltortog 0 RuldDDIW
D MoalclpaVPobUc D lodllllriaUCa........W D Agrtculwral
0 Rot:overy 0 IDJacdaa 0 lrrlgadao
00ihcr0iatUie) ___________ _
3. WELL LOCATION:
CoUNTYiradell QUADRANOLBN.AMB ____ _
NBARESTTOWN:..::M~oo~re~s~vl~lle~--------
(SimiiRoodN_N_, Cammueii)I,Suhdl-LotNo.-.~ZipCodrr)
TOPOORAPHIC I LAND SB111NO:
IZISiope OVoUey OP!at 0Ridgo00ihar, ______ _
(Cbeek appropriate aettlnB)
LATII'UDE N 35.57:::625=-----
LONOrrtiDE W 60.62:=0:=;36=-----
LadtudeJloagltuda 1ource: 121 GPS DTopogropblc map
(L«:.atltm of 'Mil rnrut 1Js1hown on a USGS 10pr1 miiJ' and
.mw:Jrod Ul rhbftmn If 110111111111 OPSJ
4o. FACU.ITY."IJm...., atlbo lnalaou wl=lbo wdl b lo-.L ComplolD ~~ lml4b.
(!fa noldlaiJd ...U. oldp ~rr: """""""4b, wtll....., lalhrmoJlca aaly.)
FAcu.ITY m #Of applicable) NA
NAME OF FACIL!TYMoore..:.svl:::,;;.lle""'M:-:;:;llls-------
STREET ADDRESS 476 South Main Straet
Mooresville NC 26115
City orTowe Slnle Zip Coda
4b. CONTACT PER!iONIWELL OWNER:
NAME Cherokee Investment Services, Inc.
STREET ADDRESS 111 E Hargett Straet, Suits 300
"Ra.lei h NC. a. Co 0 I
s. W11LL DETAIUII
a. TDlDI Dcplhr 42 II. Dlamc""' 1 io.
b. Water Laval (Below Mcaaurlr!s Polat): 23.60 11.
MCIIIIIrloa polct Ia 0 II. ob.,.lcod ourtbec.
.. CDiioa Deplh OfkDDwo):
b. CDiioa Removed:
Laaglh
.:;;27;-_ll. ..:0~_11.
7. DIBINFECTION:..:NA.::.;.. ____ _
(AmDlllll of 65%-7516 Cll!clum bypocblariln used)
8. SEALING MATERIAL:
_..1 ,--Ia. 0 ~ ..;;_ __
Nrer Crmrn• Spnd QmtMJ!
Camauu.;t=2~0==1b. Water~ ~
BcntRPIIp
a ..... ,,. 0. 5 lb.
Typo: Ill Bluny OPoUab
Water ~
ll.I!!K.
~~~NA~-------­
Arnouot..:.N"-A'----------
9. EXl'LAIN METHOD OF EMPLACEMENT 011 MATEIIIAL:
Sur(aCB Pour MethOO
10. WELL DIAGRAM: Dmw a dctaUcd olcotdt oflha weD 0111ha back oflhil
lbnn lbowfr:s 101a1 dapllr, dcplh aad dlaau:1cr or ....... (lfaay) n:malolos
lo lha wall, amvallalcMII, iolcmllo of caalos pcrforatlo01, aad deplha aad
typca of Dl1 materials used.
S10NATIJRBOJI' PRIVA.'I'E WELLOWNERABANDOHINGTBE WELL DATE
(11:apdma...Ua....,_boaladMrludwiDIIDBJIIIb:-tdln:or:abb:adalwcU
lru•a:owrar wflh t.sANCAC2C .Dtt3J
Gary Fischer
PJUPtfBD NAME OJ' PERSON AJWIIDONINO TUB WELL
Submit a apy ta tbe CIWilCI' ud the Dl'fclnlll ta lha DlYblaa orWator QIUlllty wllhlll 30 dara. FormGW..:JO
lb:v. SI!Ui AUo:lalbrmodao Maoapmoo~ 1617 MaD Strvlca Center-llrlll!lsb, NC 17699-1617, Pbooe No. (Pill) 73J.7015 ut 561.
a "llfll
w:Cw
a~ {Jvl
CIA sJ 119 ---.~ o-Jr' .
,
..
WELL ABANDONMENT RECORD
North Carolina Dopartrnent ofBnvirooment 1111d Nablml Rosourcca-Divlolon ofWoter Quollty
WELLCONTRACTORCERTDnCATI~O~N~#~3~~~9~=============--------------,
I. WELL CONTRACfORI
Gary Flscher
Well ConlniCIOr (Individual) Noma
Mid-Atlantic Associates, Inc.
Well Conlraclor ComJIIIDY Nama
STliiUlT ADDRESS 409 Rogers View Court
Ralalgh NC 27610
Cl!¥ or Town SIIIIC Zip Coda
c!!!!..J-250-991 B
An:a codo · Pboao number
l. WELL INFORMATION:
SITE WELL IDf 0£appll=blel,,_;MW='--6~--------
STATE WELL PERMIT# (lhpplicable).:.;NA:..:.......,-------
COUNTY WELL PERMIT# (ICapplicableo,_;l Nc,:A:..:_ _____ _
DWQ ar OTHER PERMIT# (lfopplicabla)c.;.NA.;;..;.. _____ _
WELL USB (Cbaak applicable Ula): IZJ Monllorlag 0 RullleoUol
0 MW>Idpai/PubU. 0 llldulrloUCammen:lol 0 Agrlcultunl
0 R«<YYIry 0 lnjO<Uoo 0 lnigoUoa
OOtbar(llatusa) ____________ _
3. WELL LOCATION:
COUNTY Iredell QUADRANGLE NAME ___ _
NEAIIESTTOWN: ..:;M;.:;oo=re::S:.:.vl:.::lle=----------
(S"""'''ood-~~-.~. Subdlvblaa, LatNa.,P""'~Zip Cada)
TOPOORAPIUC I LAND SI!'!TING:
Ill Slope 0 V.Uoy 0 Plot 0 llldge 0 Otbcr __ .;_ __ _
(Check appn>priato ..ulag)
LATITUDB N 35.5n'-'5:.._ __ _
LONGIItiDB W 80.81:.:8:::;63:..._ __ _
.... bale...,...,
--arlaa --
LatltudrlloagltadaJolln:e: ~ GPS ClToposrapble: map
{Lot:atlon qfweil m1111 be 1hown on o USGS lopo mop tmd
.ntadlaltDtht.fono(fnDtum.gOPIS.)
.Ca. P'A.CU..ITY•TbamuDD oCtbDbuslnca whaa thawcU b kx:alcd. Complcta4aaud4b.
(lfarafdcadd weU. aldp4a; camp1ata 4b1 wall owaertnfbnnadoacmly.)
FAClLITY m IOfappll=blc) NA NAMBOPPACIIn'YMoore·-=svl~lle~M=llls:-------
STIIIUlT ADDRESS 476 South Main Street
Mooresville NC 28115
Cl!¥orTOWD Zip Coda
4b. CONTACf PERSON/WELL OWNER:
NAMB Cherokee Investment Services, Inc.
STREET ADDRESS 111 E Hargett St(eet, Suite 300
~\ei h N(! d1 01
B. WELL DETAILS:
7.
B.
a. Tatol Dcptbl 35 fl. D-1 Ia.
b. Wotor Lavcl (Below Moasuriog PolnQ: 26 fl.
Moasuriog point II 0 fl. abow load 1111ri11ca.
CASING: Laastb Dlamator
a. O!slog Deptb Ofkoowu): 20 fl. 1 Ia.
b. Caalag Rl:mavcd: _,_ __ fl. ~ lo.
DISINJiliCTIOl'b .:.NA=-:_ ____ _
(Amouot or 65%-75% colclum lln>o<blorlto UICd)
SI!ALING MATERIAL:
Nrpt C,mgnt
Cam:'-j-ii20"--_lb. Wator .5 pl.
llmilmlll.o.
Baotonito 0, 5 lb.
Typo: Ill Sluny 0PcUcts
w-pl.
llllw:.
Sgnd Cement
Camoot~;:O;...__ib.
WatorU pl.
~~~N~A;..._ __________ __
~~NA~----------------
9. EXPLAIN METHOD OllliMPLACEMI!NT Oil MATERIAL:
Surfa"" Pour Method
I D. WELL DIAGRAM: D:aw a dclollc:IWtcb ofthq well oo tbo back of this
ronn •bowlos 1o1c1 dcptb, daplb aod dlamc/or or-Of Oil)') nma1n1na
In tbo well, gravcllntcml, lulcrvaiJ ofoulos padbnllio01, aod doplblaod
lypel of 611 malerlala UlOid.
SIGNATtJR.£ OP PRIVATE WELL OWNER AJIANDONIN'Q TUB WELL DATB (Tho......., ... u....., ..... boa::&uiMdmdwlooiiiiDIIIIIIIltabaadoalblrlbor ... ldaulai...U
Ia IICCCIIdo!m:o wiiii15ANCAC2C .01 11)
Gary Fischer
PRINTED NAME 01' PERSON ADANDONINO TIIB WELL
Submit a copy ta tho owaer ud the orlglaal ta til a Dll'bton or Water QaaUt;y wltblu 30 dAyL
Attu:laformaOoo Maoagomea~ 1617 MoD SU'Yioo CODlu-Ralelab, NC 2769J.1617, Pbaae Na. (9111) 7»-7015 ul568.
showing total deplh. depth and diameter of
scnoeos remaining iD the wall, gmvel iuterval,
iutervala of casingperforatioos, and depths and types tr:7 of,fill materials usod. fll W_-b ('/19t. HI
. f/' fvL Ctt~}, ~ :--.,-. .---i
I)-"2V'
r
•
WELL AQANPONMENI MCQRD
North Carolina Department ofEnviroomcnt aad Natural Reaouroea-Division ofWater Quality
WELL CONTRACTOR
1, WELL CONTRACTOR!
Gary Ascher
WaU CanlniCIOT (Jndlvldual) Name
Mld-AtlenUc Assoclatas, Inc.
Wall Coolnletar CompaayNama
STREBT ADDRESS 409 Rogars View Court
Relelgh NC 27610
CltyarTawn State Zip Coclo
c!!LJ-250-9918
A= code • Pbcao 1111111bcr
:1. WELLINJ!ORMAnON:
SITE WELL m I OfoppUoablo),.::Mo:.;Wc:.-8..=... _______ _
STATEWELLPERMlT#(IfappUoablo)r.:.N::.A.:.....,....-----
COUNTY WELL PERMIT# (ifappUcablo)r..:N.::A_:_ _____ _
DWQ or OTHER PERMIT# (irappHoabla).:,NA:..:... _____ _
WELL USE (Check appUcablo uao): Ill Moaltartnu 0 Ruldeodol
0 MDDldpoi/PabUc 0 llldaJtrlal/Cammerdlll 0 Agricultural
0 lle<Dwty 0 iiiJcctleo 0 lrrlplloo
OOihcr(lfltUJo) ___________ _
3. WELLLOCAnON:
COUNI'Y Iredell QUADRANGLE NAME ___ _
~TTOWN:~M~DO~r~es~v~l~lle~--------
(S.....nlood"-N-~,Su-LaiNo.,,...~ZipCado)
TOPOORAPHIC I LAND SBTI'IN!l:
IZISiape 0Vallcy 0Piol 0Rldga001hcr~----­
(Cbcok app:upriola -B)
LATrrUDB N 35.573::22=---
LON011111lB W 80,81:..:7,::6 __ _
Moyboll:-
m!aulcl, accaada. or !a • --
Latlludrlloogllad01oa"'"' IZIGPS OTopoiiJ'Ilpbl• mop
(LDOOtton ofwllmustlHJ •iu>1m on o USGS topo m"'' ond
onaduld to th16fonn If not 1111"11 OPSJ
4o. FACILITY· 'IboOIDII aflbo bUJioau wbua lbo ...U I>......,_ CamoloiD 4a ood4b.
(IC• ruldaada1 wall. akfp 41a; camplcta 4b, wdl awaar IDRH'auldao aaty.)
FACILITY m l(lfoppUoablo) NA NAMBOFFACJLli'YMDores=vt";;l;:le-;M~I;;:'IIS:-------
STRBBT ADDRESS 476 South Main Straat
Mooresville NC 28115
CltyorTawn Stalo Zip Code
4b. CONTACT PERSONIWI!LL OWNER!
NAME Cherckee lnvesbnent Services, Inc.
STRBBT ADDRESS 111 E Hargatl Street, Suite 300
lei h NC <)7!.PO
a. WELL DETAILS:
a. Tolol Dopllu 14 ft. Dlame:er: 1 1D.
b. Wolar Lewl (Balow Moasurios Folot): 9.90 ft.
MCIIIIIriu& polalla 0 ft. obDWIDacl aurll:co.
6. CASING:
a. Caalos Doptb Ofkaawo):
b.O:olosRanovcd:
Leosth Dlamolar
.;4 __ 11. 1 ln.
..:_ __ ft. 1 lu.
7. DJSINFECnON1 ..:.NA::..:., ____ _
(Amouol of IIS'I!.75% colciWD bypodllorilo UICd)
NrntCrmrnl
Ca111011\_,13~_1b. wo~ar1 aoL
Qglpqlft
BoaloldiO 0 ,'!) lb.
'l)'po: Ill Sluny 0Pollcla
Wolar aoL
&pad Q:mpnf
!lll!!r.
~~~~NA~-------------­
-~NA~----------------
9. EXPLAIN MEmOD OF EMPLACEMENT Ol' MATBRIAL:
S1nfaM Pm•r Method
10. WELL DIAGRAM: D:uw adotalled Wtab aftbowaU 011 tbobockaCtblo
rom: abowlos 1o1o1 dcptb, doptb ood dl::molorar ....... (lfooy) RmDialoa
Ia tho waU, JIIIMI(Iatavol, I:W:rwlaofcoalos~ ood dcptbo ood
typca of flU moiCdall..,.,
SIGNATURE OF PRIVATE WELL OWNBRAIIANDONJNO TUB WELL DATE (lbo,.n-...u ..... -""'"lodhtdudwlmiiDI!IIIIIbt_ldab_ ...n
lo ............ wt:bi5ANCAC2C.OII1)
Gary Ascher
PIUNTED NAME OJ PERSON AILUIDONJNO TBB WELL
Submit a eopy ta the owaer aad the orlglaal to the DJ\'bloa ofWatar QaoUt)' w1lb1u 30 daJL PonaGW..lO
Rav. 5/06 AIID: lllfarmaUoo Mooogua10~ 1617 MaD Senolco Contor-Ralol&b, NC 2769!1-1617, Phooa No. [phone] at568.
0 •• IIIII
. ..aka
' .
'
WELL ABANDONMENT BECORP
North Carolina Department ofEnvironment and Natural Resoun:ea-Dlvlaion of Water Quality
WELLCONTRACTORCERTDnCATI~O~N~#~33~3~9~============:--------------,
t, WELL CONTRACTOR:
Gary Fischer
IITREilT ADDRESS 409 Rogera View Court
Raleigh NC 27610
City or Town Stola Zip Code
~. 250-9916
Araa coc1o • Pbouo aumbor
Z. WELLINFORMATIONo
SlTB WELLfD # Qfappllcabiii)I.!!M:!!W'-!."8=1 --------
STATEWELLPERMIT#(Ifapplic.J,IooJ:lNC!A~-------
COtiNTY WELL PERMIT# (lfappUcabiCoJ.l :.:N::A:...,. _____ _
DWQ o;OTBER PERMIT f (lfappUcabiColl N:,:A~-----­
WELL USE (Cbect appUcabltl usa): Ill Moollorlag 0 Resldmllul
0 MunlclpaVPubUe 0 loduslriaVCammardal 0 Agricultural
0 Rocovorr 0 lojcctlaa 0 lrrigadoa
0Dihor(llatuso) ___________ _
3. WELL LOCATIONo
COUNTY Iredell QUADRANGLBNAMB _____ __
NBAIIESTTOWN: ,::M:::oo=re:::SC!.VI:::lle~--------
(B.....ntoad--,CammaaiiJ,Bubdlvblaa,LotNo.,l'l&al, ZlpCodo)
TOPOGRAPHIC I LAND SJnTING:
IZJSiopo 0Volloy OJ'Iat ORidsoOOihorc...._ ________ _
(Cbcck appruprlato IIClllusJ
L\TmiDE N 35.57~322~----
LONGIIUDE W 60.61!..!7~6~6 __ __
Lotllodellongllada IOURU Ill GPS 0 Topogropblc mnp
(Loct:t/Dn q/'1..0 muJt /uJ lhown on a USO!IIDJH> map and
oltll<htd., thlsfonn If not udng GPSJ
4o. FACILITY-1ba DlliDI af'tba 1N11acu wbcnllba wdl II IDeated. ComplctD 4a and4b.
(!Co nuldanlal w.U.IIdp 4o; """'''I~ 4b, ...n"""" lnlbnalllloa only.)
FACILITY m #OfappUcabiCJ.!N~A~=:-------­
NAMBOPFACILIIYMooresvllle Mills
S'I1UlET ADDRESS 476 South Main Street
Mooresville NC 26115
CilyarTown ZlpCodo
4b. CONTACT PERSON/WELL OWNER:
NAMB Cherokee Investment Services, Inc.
BTRHili.ADDRESS 111 E Hargett Street, Suite 300
I i NC d'1 01
&, WELL DETAILS:
L Tolal Doplb: 35 ft. DltlmOICr. 1 iD.
b. WDICrl.llwl (llclow Mo:amrlas Palntt. 10.13 ft.
M.....,u,g polnlb 0 ft. ebo,. bmd aurtbec.
6. CASING: Lonatb Dlamotcr
30 ft. 1 iD. L Coeloa Doplb Cfkoowo):
b. Coalns Removed: ..:._ __ ft. ,--iD.
7. DISlNFECTION: ..:.NA:::.:_ ____ _
(Amauat or&,%-75% caldum bypacblarllo used)
8. &BALING MATERIAL:
Nee• cement
Ccm<nt 20 lb. WDICr\!,.2=--pl.
Bcptgpltg
Bonta::IID 0 • '5 lb.
Typo: Ill Sbmy 0Pollols
Wlllllr pl.
Qlh!t
Sgnd Crmgt
Cnmcooj;tO,_ __ Ib,
watorO saL
TYJICI mata~a~..:.NA.::..:.. _______ _
Amn~,.~N~A~-------------------
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIALI
SurfaC!! Pour Method
10. WELL DIAGRAM: Dmw o delallcd oblclo oflhoweU oolho back ollblo
fana •llowloa lolal depth, doplb and dltlmotor or 101110111 (If IIIII') I'DIIIIIIaiDJI
In tbo wei~ IP"Yollnlcrwl, intmvolo orcaoJCg potf'llllllfo:u, and dopdnt and
types of ml motcriAis UICII.
9/3/09
SJGNA.1'llRBOBPJUVATEWELLOWNERABANDONJNOTBBWELL DATE
('llulpdnuo ...n--looaiadMohmlwboJIImlllllr._loblbcr_ ...n
Ia. accardaaal wbh UA NCAC 2C .0113.)
Gary Fischer
PRINTED NAME OF PERSON AIIANIIOIIIIIOTBB WBLL
Submit a a~py to die owucr 1111d tbe orlglual to lba DhrbJoa or Water Qd8llty wllhla 30 deJa.
Attn: laformailoJJ MniiDIInmm~ 1617 MaD s.m .. Contor-Ralcilfb, NC 1709-1617, Pbane No. (919)7.13-7015 ut 568.
I
EJ
sbowing 10tal depth, deplb and diameter of
SCietliiS remaining iD the well, gravel inlerval,
iutenlals of casingperfmations, and dep~ typ~
offiD maleriala used. /1) W _ .p_r l/ 1.1/'-.. 0.t-_j
I •
_:-"'f!tt/A~
__,... 5fl1J./ _. 7 ~ ').j/· 3S'
-T.IJ.
J.s-'
WELL ABANDONMENT RECORP
North Carolina Dcpllllmcnt ofEnviroaiDOilt and Natuml haD"'""-Division ofWater Quality
WELLCONTRACTORCERTDnCATI~O~N~#=~=3~9===============--------------,
1. WBU. COIITRACfORI
Gary Flschar
Well Coalluclar (IDdlvldunl) Namo
Mld-ManUc Assoclatas, Inc.
Woll CaolloctorCompiDyNomo
STIU!I!T ADDRBSS 409 Rogara Vlaw Court
Ralalgh NC 27610
CityorTowa SIBIO ZlpCodo
c!!I!...J-250-9918
Ala code-Phoaa awnbar
2. WELL INFORMATION:
SITE WBLL m I (ifappllcablo)..::M..::W..:.·..::9 _______ _
STATE WBLL PERMIT# (lfappUcabto),.:.;NA::..:.. ______ _
COUNTY WBLL PERMIT# (ifapplh:ablo),.:.;NA::;:_ _____ _
DWQ o~ OTHER PERMIT# (If appllcahto),..:.N::.A.:,_ _____ _
WBLL USE (a...k appllcahlo1110): 1ZJ Manltorlag 0Raldoodal
0 Moolo:lpal/Publlc 0 IDd .. trlaUCoi!UIICI'dlll 0 Agrlcullunl
0 Racovery 0 lnjactloa 0 lrrlpdan
oo~om·~~--------------
3. WELL LOCATION!
COUNTY' lradall QUADRANOLSNAMB _____ __
~TTOWN:..::M~oo~ra~S..::~~IIa~--------
(SinZIIlload N-NIDDioar, Co-, Sobdl>bloo, Lo!Na.l'mcc~ Zip Coda}
TOPOGRAPHIC I LAND SI!'ITIND:
IZJSiapo OVII!Ioy qP!ol OatdpOO~~----­
(Cin:ck appmpdato llltdoal
LATITUDE N 36.67::::33:::2:_ __ _
WNOITUDEW80.81~7~09~--­
LaUtaclellanglluduourc~~ IZJ GPS 0 Topof11'11pblc map
(Lo<tiiiDn qfw.J/mUJt be rhownon o USGS IDpo ""'P and
allrlf:Md ID lll/8farm If nat filling CJPIIJ
41. FACILITY· TbPI!a altha tna1m:a wbcm IIIII wtU llloclla:d. Catap1c&a 4a aad4b. (Ita--U!p • ., ....,!Qa4b, ...U ...,...lnf"""""• 011\Y.J
FACILITY m N(lfappllcahle) NA
NAMB OF FACJLilYMOOrBS..:.Y.::,I;,.IIa--,MJ=IIs-------
STIU!I!T ADDRBSS 476 South Main Straat
Moorasvllla NC 28115
CltyarTowu SIBIO Zip Coda
..
6.
7.
8.
WELL DETAILS:
a. TaiBI Dopllu 15 ft. Dlemoter:1 ln.
b. wo~er Lovcl (llc1ow Meosurioa Point): 12.46 ft.
M......;.gpolotll 0 ft. abo ... lead ourflu:o.
CASING: Looatb Dlemoo:t
5 ft. 1 to. a. Coslos Depth (lflcuowu):
b. Coslog lll:mtm:d: ft. ~ ...
DISINii'I:CTION1 NA
(Amouat o£6S%-mlo calclwa bypacblorll<l IIICd)
SEALING MATERIAL!
Ncnt Cmnrn'
Ccmcot,..:.13~_1b. wa~or1 !!IlL
llmllml1a
Bcataalta 0 • '5 lb.
Typo; IZJ Slwey 0Pcllata
Wider !!IlL
£lllllt
Bppd Cfmmf
Cemeot;rO:_ __ Ib.
Wider U !!IlL
Typo mall:rlal.:.;N::_A::..__ __ __.. ____ _
Amowu~NA~--------------------
9. EXPLAIN METHOD 011' EMPLACEMENT 011' MA1'EIIIAL:
Surface Pour Method
10. WELL DfAGRAM: Dmw a detailed ola:ICb oftbe woO aa tbe back oflbll
rona •bnwlogloiDI daplb, dapth oad-oCICIIIOI (ifaey) lllllllllalog
to tbe wol!, araYO!Iall:mll, laletwll oCcufna ~ oad claptlul oad
types of fill materials Oiled.
IL DATE WELL ABANDONED ..::9::,:131::.;0::9:...,_ _____ _
SIGNATURE OP PRIVAT£ WELL OWNERAIWfDONING TBE WEU. DATE
(lba prtva&oweUowacrDSUI&boa IDdlvfdu1 who ...UX,abam!oml bllll=aldadfd Will
klllccmdo•a"'bb ISANCACZC .OII>J
Gary Flschar
PJUNTED NAME 011' PERSON ABANDONING TBZ WELL
Sabmlta copy to tbe owau aad tbe orlglaal to tbo DIYIJ!oa or Water QaaiiCJ wttbfa 30 dayL l'annOW'iiO a. •. S/06 Atlu11Dfonnadoa Manopmon~ 1617 Mad Senko Crater-Ralelllb, NC 2769g.1617, Pboae No. (!119) 733-7015 ell568.
"'
~
A1'LANTIC ••m'""' ...,.,_.. FliiW ...
OCIA.TBS, P • .A. .. =:... .... 'Aidmi IIEliElL. IDIHJY, .... CAIII.IIa
showing total deplb, depth 1111d diameter of
screens remaiuing in lhe well, gravel ioterval,
=.==~.no~iv~t(ij;~
rlfvL
{, li5tli ~ .
0'$''
J."' 1(/L-
~crrM
/0 ) ( 5'-tS
,
,
twW
O•/s'
:. -_.p;-z, W?l{
'· fiJI [Pr/ .
. s'-JS'
,
-r;f),
tS''
WELL ABANDONMENT BECQRD
Noltb Carolina Department of Environment and Natural Reacnucea-Division of Water Quality
WELLCONTRACTORCERTIFICAT~l~O~N~#~3~33~9~=============-------------~
1. WELL CONTRACfOR:
Gary Fischer
Well Cen-(lndlvldwll) Name
Mld-AUanUc Associates, Inc.
Well Cenoactor ComJliiiiYNama
STlU!I!T ADDRESS 409 Rogers Vlaw Court
Raleigh NC 27610
CIIJI or Towa SIDID Zip Coda
c!1L>-250-9918
Alaloodo-Pboae number
2. WELL INFORMATION:
SlTBWELLlDI OfoppllcobiC•l~e MW~~-1~0~-------
STAT£ WELL PERMlTII (lfappUcablc)'.!:N~A~-----­
COUNTY WELL PERMlTf (ll'oppUcableolJC N~A~------
DWQ or OTHER PBBMIT # (lfawUcable)'.!.N:!A::_ _____ _
WELL USB (Cbeclc oppHcable usc): Ill Maoltarlog 0 Raldeodal
0 Muoldplllll'ubUc 0 IDdwlrlai/Cammo:rdal 0 Agrlcallunl
0 Reeaveey 0 IDJccUaa 0 IrrlgaOao
00ihcr(l&tuac) ___________ _
3. WELL LOCATION:
COUNTY Iredell QUADRANGLE NAMB _____ _
NBARESTTOWN:~M~oo~res~~~lle~--------
(&....nlaadN-Noaabcr, Ca-,Subdlvlalaa, LeiNo., p..,.~ztpCadc)
TOPOClRAPHIC I LAND SB'11'1NCl:
ll)Siape 0Valla)o OPlat ORidscOOihorc _____ __
(Cbcck llpJIIIl(lllalo sciUag)
LATn'UDB J:! 35.57:!.41!..,_ __
LONCll'IlJDB W 80.81!!9~9~5 ___
LalltuclelloaghudeJourcel liZI GPS OTopograpblc map
{Lal:ull<m of...O m111t bs 1/unm anD USGS IDpo map and
DltrH:I111tlto thiljbrm lfNJt wlntl GPSJ
4a. FACILITY. Tbo 1111D111 aftba budzu:u when the well Is locD&cd. Ca~-. aad4b. (II'•-...u, '"" ... _ ....... welt"""" lolbnuodoaaaly.)
FACILITY 1D 10foppllcablc).!.N::;A;,....,=-------
NAMBOFFACilJ'IYMOoresvllle Mills
STlU!I!T ADDRESS 478 South Main Street
Moore~lle NC 28115
CIIJI orTowa State Zip Coda
4b. CONTAcr PERSON/WELL OWNBR:
NAMB Cherokee Investment Services, Inc.
STREET ADDRESS 111 E Hargett Sl{eet, Suite 300
'Ra.l ei h, NC. ~'llpDf
I. WELL DETAILS:
a. Tolal Dcptlu 20 11. Diameter: 1 Ia.
b. w .... u...J(IIalawMasuriuaPolal): 14.19 11.
Mcasur!os prim II o ft. Bbowlaod IIUrlhoc.
6. CASING: Lcastb Dlamctl:r
.. Collai Daylh 0£1mawn):
b. Casias llcmovod:
..;,1n.-o_ 11. 1 1 ..
.:!0:::.5:..,__ ft. ,--Ia.
7. DISINPECTION: .!.NA=-----
(Ammmt of6SI!r-75% Gllclam bypocblarilo usod)
B. SBALJNGMATERIALl
Nrpt Cement
Ccmeat-;,1~3 __ lb.
Wat..-1.5 pl.
Bentgnho
BcoiDollll 0 .'5 lb.
Type: 121 Slun)' OFellctl w.... pL
lllbu.
&ggd Crmcgt
c ........ f.o==~lb-wa~u..!l pl.
'J'Ypc malllriai,:NA.:..:. ________ _
~.~NA~----------------
P. EXPLAIN Ml!TBOD OP EMPLACEMIINT OP MATBIIIALI
Smfape pour Method
10. WELLDIAGRAM:Dmwodelallcdmt&:boflhniiUoolblbadto£lhll
rorm •bowlas to1111 dcplh, depth 01111-or-Oflllll'liiiiiiBlalua
ID lbl well, gnmllotcml, lalllrwiJ ofCIIIIIIS podbradoas, ood dcplbl and
IJipCS o£fillll1lllllrlallao.S.
SIGNATURE OF FRIVATE WELL OWNER ABANDONING TB£ WELL DATE (n.pdvllo..U--bo .. _wbo ____ ..u
............. wllb !SA NCAC 2C .01 tlJ
Gary Fischer
PllllmiD NAME 011 PER50N ABAlOJONING TB£ WELL
Submit a copy to tho owaer DUd the orlglDal to tbe Division atWater QIIBllty wltbla 30 do)'L FormOW..1D
Rcv.5106 AUo: IofarmaUao Maoogameo~ 1617 MaD Service Caotu-Roldgll, NC 276P!I-11i171 Pbaae Na, (PIJ) 733-7015 ut 51111,
weD showing total depth, depth and diameter of
screeus remaining in the wei~ gravel iulerval,
iutmvala of casiog porf'oratiom, and depths and types
of fill maleriala used.
mw-/o(f~
·-).(},
~I
WELL ABANDONMENT BECQRD
North Carolina Deportment ofEnvironlllllllt and Naturnl Resources-Division of Water Quality
WELL CONTRACI'OR CERTIFICATION
I. WELL CONTRACTOR:
Gary Fischer
WaD eoa ...... (ladlvldual) Noma
Mid-Mantic Associates, Inc.
Well ConlrDctar Compamy NIIDIO
STREET ADDRESS 409 Rogers VIew Court
Raleigh NC 27610
Chy or TDWD Stoto Zip Codo
~-250-9916
Aroa coda-Pboae number
:Z. WELL INFORMATION;
SlTB WELL m t QfappDcoblalcM::.W:..:....;-1:..:1 _______ _
STATE W1!LL PERMITS (lfapplli:abla)cN.::A::..._ _____ _
COUNTYWELLPBRMIT#QrappUcabla)..:N.::A~------
DWQ or OTHER PERMIT# Qrapplicobla)~.;N..::Ac.:._ _____ _
WELL USE (Cbcckapplicabla 1110): Ill Monllorlug 0 Ralldaotloll
0 Munldpoi/PubUo 0 ladiiJirlnliCommordal 0 Agricultural
0 Reeovory 0 loj .. Uao 0 lrrlgoUan
OOiherQlatusa) ____________ _
3. WELL LOCATION:
COUNTY Iredell QUADRANGLE NAME ____ _
~TOWN:~M~o=o::.re=s=v~UI~e~--------
(SirectiRoad NIIIDII1 Number, Ccnaaaall¥, 8ubdJW!au. Lot Na. Pucal. Zip Cadc)
TOPOGRAPHIC I LAND SSTriNO:
Ill Slope 0Vallay OFiat ORidgaOOih..-c..._ ____ _
(Cbook opp;apriato 10ulng)
LATITUDE N 35.574::..:7..:::3 __
LONGmJDE W 80.81:..:8:::5:;.8 __
LaUIUdo/laogltado IODI'Cil Ill GPS 0 Topagrapblc map
(l.o<atiDn qfwlll most 1Hz 1hown on a USGS topo map and
otlrll:lu:d to thbf.,.,.lfnat IUIIIIJ GPSJ
411. FACILITY·1baiiiDIO atlha .... laoosw"""lbo ....Ub ........_ <:a-4·-·
(lh-...U.IIdp 4a; ............ ....u """"lalbmadaaaaly.J
FACILITYW#QfappUcabla) NA NAMB OFFACIL!IYMoore.:=-sv";li;-lle~M=ms ______ _
STREET ADDRESS 4 76 South Main Street
Mooresville NC 28115
City or Towa SIDID Zip Coda
4b. CONTACT PERSON/WELL OWNER:
NAME Cherokee Investment SaiVlces, Inc.
STREET ADDRESS 111 E Hargett Street, Sulta 300
'Ra.lei h Nt a IDO
._ WELL DETAILS:
a. Tolal Doplb: 44 11. Dlamalcr.1 Ia.
b. WDIDr Level (Billow Ml:lllllriq Polul): 40.00 11.
MOIIIIIriq palalla 0 II. abovo bad JUrihoa.
6. CASING:
a.CaslaglloplhQra-): .;;2::.9 __ 11. 1 Ia.
b. Caslagllaaovod: II. ,----Ia.
~ DU~ON:.:'NA~----------­
(Amoaot of 651!. 7~% oal::lum hypoohloriiD used)
B. SEALING MATBIUAL:
NeptCmanl
Camoat,=2=.0 __ 1b.
Wator2 gaL
Btgtonllt
-.. o.IS 111.
Typo: Ill Sluny 0Pollall
Wator gaL
SnndCmmt
clllllllll\l!... 111.
Wat<ru-----gaL
Ol!!!t
T~OIDIDrid~NA~---------------­
Amwm.:'N~A~----------------
9. EXPLAIN METHOD OF EMPLACEMI!Nr Oil MATKRIALI
Surface Pour Method
10. WELL DIAGRAM: llnlw a d...Uod olcaiDb oftha wall oa tha back oftbla
lbnn obowlag talal daplb, daplh and dlamctar or ....... QrzmY)nllllolaiDs
Ill tha wall, J1111valiDIDmll, .._,.. ofllllliD&poribralloua, aad daplhl aad
lypCI of fill IDIIIDrinll ......
SIDJIATIIIIE OF PRIVATE WELL OWNER ABANDONING Tllll WELL DATE (lbo,.._,.,u"'""''""'bo'"-•..........a---...u ta accmdiiDcD w11b ISANCAC 2C .0113.)
Gary Fischer
PRINTED HAM£ OF PERSON o\IWIDONINO THE WELL
Sabmlt a copy to the owner aad. the orfulaal to tlut DJvbloa of Water Qa.allty wllhla 30 da)'L Fonaow.ao
Rov.5106 At11nlaformaUoo Maaapmao~ lfl7 MaD Sarvloe Cealer-Ralalgb, NC l761J.I617, Pboae No. (tlll) 733-7015 u1 568.
I'
'
1!1i 1la!···Sh El
shawiug tolal depth, deptb Blld diamr:ter of
scn:ens l1llllllillins iD lhewel~ gravel iDtmval,
intm'vab of casiDg perforations, and depths and types
offiD matmialsused fi1J!;j_/ (/lf/8 lJ)
tletf, ceneJ; Jill /v(; , ~ tJ ,. '( '(
C6 .SJ/If--t; o-2tl,
r
..
.. -If] J,4~d/
: flvd. ~,;J
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WELL ABANDONMENT BECQRD
Notlb Carolina 0cpiU1mcnt ofEnvlraiiiiiCIIt and Natural Raoun:os-Dlvisloo of Water Quality
WELL CONTRACTOR
I. WELL CONTRACTOR:
Gary Fischer
Well Coatmctar (lodlvlducl) Name
Mid-Atlantic Associates, Inc.
Wcll Cootnu:lor Ccmpooy Name
STREBT ADDIU!SS 409 Rogeru Vlaw Court
Raleigh NC 2761 D
City or Town Slolo Zip Code
~-250-9916
Aloa codo -Pboae number
2. WELL INFORMr\'110N:
SITII WELL m t (lfappllccbkio"l M=W:...-1.:.:2:.._ ______ _
ST.r\TBWELLPERMITII(IfcppUcabloc!N,:A:.:... ______ _
COUNTY WELL PERMIT II (lfappllccblc).!:NA=--'-----
DWQ or OTHER PERMIT# (lfappUIISblc).;..NA;;..:.. _____ _
WBLL USE (Cbook oppllccblo uoc): Ill Maaltarlq 0 a..tdcatllll
D Moalclpalll'abUc D ladutriiii/Cammordal D r\grlcallurol
D Rccavoey D IDJecUaa D lrrlgaUaa
OOibcr(lbtUic) ____________ _
3. WELL LOCr\'110N:
COUNTY Iredell QUADRANGLBNr\MI! ----
~TOWN:.:.:M~oo~~~SV~II~Ie~-------
(S......,..,._.N_ N,....,, C:.-, S"""vfll<rl!, l.oiNo.,Pucoi,Zip Cad<r)
TOPOilllr\PHIC I Lr\ND SI!TI'INO:
IZJSiapo 0Vclloy OF!ct 0Ridp001bcr-'------
(Cbeck cppropriala IOIUag)
Lr\TmiDI! N 35.574.!:0:.:6'----
LONOmiDB W 60.81~8::::39::..... __
Mqbola---..... --
LoUiudello"811Ddc '""""' Ill GPS D TapaJilllpblc mop
{Locotltur of well mw1 ba1/mm 011 a USGS ltJplJ map and
a1Jr1t:irt!d Ia llrbf,.lf111Jt ral1111 GP/l.)
41. FACILITY. Tba IIIUZII aru. budoca whmt lba wdllllucatl:d. Coqllo114a 11Dd4b.
(If a 111ldoolloi...U,Ildp •~ COI!IJIIalro 4b, wo11 """" lalbmmllaa DDIIJ
li'r\CILITYID l(lfappUcablc) NA
Nr\MI!OF Fr\CJUTYMOo~=sv~ll;-:le-:M7.1""11s:--------
STRI!I!T ADDRESS 476 South Main Street
MooresviUe NC 26115
CityorTowa Zip Coda
4b. CONTACT PERSON/WELL OWNER:
Nr\MI! Cherokee Investment Services, Inc.
STRI!I!T ADDRESS 111 E Hargett Street, Suite 300
"Ro.lei Nc :.?'1~0
&.
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7.
a.
WELL DETr\ILSI
a. Tatol Dcplh: 45 ft. Dlamcla: 1 Ia.
b. Water Loval (Below M1111111riDa Point): 40.99 ft.
MOBS1Iriaspolmll 0 R.ahavclood-
CASING: Lcagth DlamiiA:r
a. Ccalag Dcplb (lfkaown): 30 fl. 1 Ia.
b. Ccafns Ramwcd: ft. ,-Ia.
DISINII'EC'I10N: NA
(Amauato£~7"' calcium bypacblorllo Uled)
SEr\LING Mr\TBRir\L:
Nmt Cement SgndCpmgf
Ccmcal.::20~_1b.
watcr2 p1.
Bpnlpqllp
I lb.
1)pc: Ill Sluny OPcliell
Wator pl.
Wlllr.
~·m~~N~A~---------------
r\mcuot~N:::A!-________ _
t. EXPLr\IN METHOD Oil EMPLACEMENT OP Mr\TEIIIr\L:
Surface pour Mathgd
10. WELLDir\Gar\M:Do:waddDIIcd-attbawcDoatba-artbla
fbna lbowlag IDIIII doptb, doplb oad dlcmctA:r or..,.. .. (If aD1) lallllbtluu
lo lba wcll, &n~vallotcrval, lotarvaiJ or culos pcrfbmtloOI, oad dopllll cod
~ .. cltlllotah:riAII!IIOOI.
SIGNATURE OJ' PRfVATB WELL OWNERAD.AMDOHIHO TB£ WELL DAft
(Ibc pdwla wall """"'"'"'ba .. -wbc IIIUII!DIIIr.---wall IA-wbb I>ANCAC2C.0113J
Gary Fischer
PIIINTEII Nr\MI! 01' PEIISON r\IANDONINDTBE WZLL
Submit o ccpytalbo awocr aad lbe arlgloaltalbo Division or Water QoaUty wiiiiiD 30 dcys. FarmOW..lO
Rav. !1115 r\Uu:lafannclloa Mcaaaemca~ 1§17 Mall Scrvlca Cooter -RaWgb, NC l769P.1617, Pbaao No. (919) 7.J3.7015 ut568.
woll ahowingllllal depth, depth and diameter of
&CR>eos remaining in the well, gravel interval,
iDtervals of c:asiug ped"oratiDIII, and depths Blld types ·
of filllllllleriala used.
lf1 w-12 ( "TiAr-IT}
/-t--ed-(~
()-'t~' ~, P.uc
C{AS~Af ---tj
tJ-:}jO'
WELL ABANDONMENT RECORD
North Carolina Depar1ment ofBnvlmiUDOIItand Natural Reaoun:oa-Division of Water Quality
~LLCONTRACTORCERTnnCATI~O~N~#~3=33=9===============-------------~
1. WELL CONTRACfORI
Gary Fischer
w.u enn-. (!Ddlvlduoll Namo
Mid-Atlantic Associates, Inc. w.u enn-.ecmpmyNamo
STREET ADDRESS 409 Rogers View Court
Raleigh NC 27610
Clty orTowa BOIIID Zip Code
~-26D-9918
An:a code~ Pboao number
:Z. WELL INFORMATION:
SITE WELLm f QCappUaabiCo,.;l M=W'-·1.;.;2;;.;:8,__ ______ _
STATBWELLPERMIT#(ICappUaablc).:.;N::..;A,__ _____ _
COUNTY WELL PERMIT# (lfappUIIIIblcJ,t.:NA=------
DWQ or OTHER PERMIT# OCappUcablci.:.N::.A.:_ _____ __
WELL USE (Cbeck appUcablo1110): Ell Moaltorlag D RaldUiftal
D Manlclpai/PubUc D Indllllrlai/Comrnordal D Agrloultural
D a......., D lnJedlon D Irrlgofton
DOibcr(llatuso) ____________ _
3. WELL LOCATION:
coUNtY Iredell QUADRANGLE NAME ______ __
~TOWN:~M~oo~res~v~D~Ie~--------
(""""'Rmd-Nlomb<r,Commaalty,llllbcl1villoii,LoiNo.,Pucei,ZipCocb)
TOPOGRAPHIC I LAND BI!TTING:
llJSiopo DV&Uey OFict DRidgoOOtbor _____ _
(Check DJIPIOIIrlato IClllnal
LATITUDE N 35.6740.:.:.:,7 ____ _
LONGITilDE W ~81:.:8:::38::.._ __ _
MqbalDdlpal,
mfaula., IIIIXDII. ar Ea a
""""" lbnaal
LDUtudclloaglladesoarcm f2l GPS 0Topagraphlc map
(LocaUon qfWfl/ mUJI buhown •• o USGS topo mop tmd
ottm:hod totlu.form If not lll#ng GPSJ
4A. JI'ACILrrY·1baDIIDIII artha bullnal wbaa tho waD lllacatcd. Comph:ta "'aaad4b.
(Ita ... -1 woll, llllp 4o; ....,~~~a 4b, ... u """"lalb""l!oo omiY.)
FACCLITYmRQCappUcablo) NA
NAME OF FACIUT'I'Moore.:.sv::,ll""la""'M""I"'IIs-------
STREBT ADDRESS 476 South Main Slreet
Mooresville NC 28115
Clty orTCIWII Slalo 7Jp Code
4b. CONTACf PERSON/WELL OWNER:
NAME Cherokee Investment Servlces1 Inc.
ADDRESS111 E Hargett Straat, Suite 300
I i 1\JC. a"ll#OI
B. WELL DETAILS:
a. Talal Doplb1 25 ft. Dlam:ta: 1 ln.
b. Water Lm1 (Bclaw Me11511riua Paint): 40.00 ft.
Mc:uurinspolntis 0 11. abovalsod ..-
4. CASING: Laastb Diameter
a. Casias Doplb Qrtnawn): 10 11. 1 Ia.
b. Csslns Rcmovcd: ....:_ __ 11. ,--Ia.
7. DISINFECTION: .:..N;;.A:._ ___ _
(Amount oC &S%-75'11 calcium IIYJ:oddorllo UICd)
B. SEALING MATERIAL:
Ne•' rmqcn'
Ccm0111..:;13:::,.__1b.
Wlllllr1 goL
llllllmllll
Bontoalta 0, 5 lb.
Typo: Ill Bluny DPallatl
Wolor goL
&gad P,mrnt
Wlll!l:
~~~N~A'---------------
Amouni.:..N;;.A,__ _______ __
p, EXPLAIN METHOD OF EMPLACEMENT OF MATBRIAL:
81 Jrface pgur Method
10. WELL DIAGRAM: Dmw a dotallad 1lallch oCibo wallaolbo back oCihlll
tbna •bowlaa tatal depth, dapth aad dl .... tcr or ....... QCaay) manlalna
lo lbo wall, P'"llolomll, latcrwls of CGiloS pcrlbratlons, aad doplbo ond
typoa or fill moll:riall ......
SIGNATURE OP' PRIVATE WELL OWNER ABANDONING THE WELL DATE
(11&a prlvlm....U DWIIIr'IIUibe aalDdMdall who DIDIIIDIDI.abullam IIWhlraaldaadd Will
Ia ....,.._ wllb ISA NCAC 2C .Oti3J
Gary Fischer
fllJN'I'ED NAME OF PERSOIII ABANDOHING THE WELL
Submit a copy to tbe cnvnar aad the ortglool to t1te DIYidou olWatar Q11Dllty wlthiD 30 da)'l.
AUDtlaformaUoa Muagem.eat.1411 MaO SC!J'Yiu Cu.tu-Raleigh. NC l76'!J9.1617, Pboue No. CJ19) 733-7015 ut 568.
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C LAS;IIf' -..,... ----4
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WELL ABANDONMENT RECOBD
Nonh Cam Una Department ofBnvlronmont and Nahlml Rosowoes-Dlvlsloo of Water Quallty
WELLCONTRACTORCERTIF1CATrl~O~N~#=~~3~9==============~-------------,
1. WELL CONTRACfORJ
Ga!Y Fischer
WeU Ccolrletor (llldt.ldual) Nome
Mld-AUanUc Associates, Inc.
Well Caalrletor Company Name
STREET ADDRESS 409 Ragms VIew Court
Raleigh NC 2761 0
City or ToWD SIBle Zip Cado
t!!!!LJ. 25D-9918
Area code -Phaoe number
l. WELL INIIORMATION:
SITE WELLID I 0fappllcobio)•.::M::.:Wc;.·..:1.:3 _______ _
STATEWELLPERMIT#(IfappUcoblo),.:.NA::..:.. ______ _
COUNTY WELL PERMIT I OfappUcoblol..,NA=------
DWQarOTHERPERMITIOfappUcoblooJ.:lNA:.::.:~------
WELL USE (Check appUcoblo 1110): Ill Maallorlag 0 RuldoaOal
0 Mualdpai/PubUe 0 ladUIIrlai/CoODmordal 0 Agrlcultunl
0 lle<overy 0 loj..,Ooo 0 lrrlgoOoa
0Diber(llstUJO) __________ _
3. WELL LOCATION:
COUNTY Iredell QUADl\ANOLBNAME _____ __
NI!ARESTTOWN: .::M:::D::D::.:rBS=VI:::lle::_ _______ _
(S~ N-NIDibar, CaiiiiiiiiiiiY, Suhdhlafao. Lol No., Pucol, Zip Codo)
TOPOORAPHIC I LAND SETI"INO:
IZJSiope 0Vcllcy OPial 0Ridgc00U...c..... ____ _
(Cbcck apptOPriaio IIIIIIDB)
LATII"UDB N 35.574;:..1,__ ___
LONOl111DB W ~81:..:7.=8::.8 ___
LaOtudolloaalladeJouno: Ill GPS OTopaanphlc IIIAP
(L«:GIIDII of Will must bolthmvn on a USGIIIDPD map oad
tl/t«:6edtothbfonnlf .. t ra11111 GPSJ
4a. FACU.ITY·lba ClliiDD of'tba bUIIaaa wb:ro t11a well b lacatcd. Camplcta ~ uul41r.
(ICa-. Will, ~4a; ....,...4h. waU .....,.fctlmoollaaooly.)
FACILITY ID #Ofoppllcoblo) NA NAME OF FACD.JIYMODre&V=,I;,.IIe""'M=Ills-------
STREBT ADDRESS 476 South Main Street
Mooresville NC 28115
CbyarTowo Slala Zip Coda
4b. CONTACf PERSON/WELL OWNER:
NAME Cherokee lnveslment Services, Inc.
STREBT ADDRESS 111 E Hargett Street, Suite 300 ~alei h rJC. ncool
s. WELL DETAILS:
a. Tallll DepOII 22 ft. Dbucetcr: 1 ln.
b. w-Level (Below Meuurlna PolaQ: 6.5 ft.
Mcaaurlna palat 1J 0 II. cbaYC lamiiiUrllu:a.
&. CASING: Lcqth D~
a. Caalos Daplb Oflcaawll): 7 ft. 1 Ia.
b. Caalas Romowd: ..:._ __ ft. ,---Ia.
7. DISINIIECTION: ..:.N::.A,__ ___ _
(Amow:taf65%-75'Kcalclam~bulteusod)
B. SEALING MATERIAL:
Ncet[rmrnt
c.m ... .!1=.3 ___ lb. w-1 p1.
Bcgtqglle
Bcnlllllloa 0 .l5 lb.
Type: Ill Sluuy OPallota
Water pl.
llllw:.
Bgpd Ccment
Comoat,;O::.._ __ Ib.
wa~crU pl.
Type maleriai..:.NA::..:. ________ _
A.ODawt..:.NA::..:... ________ _
9. EXPLAIN MBTBOD OF EMPLACEMENT OF MATEIIIAL:
Surface pour Method
10. WELL DIAGRAM: Dmw e dolallcdola:u:b aflhowallaalho bcckaflbb
1brm abowlaa tata1 dqllh, doplh aad dbucctar of......, OCUIYl romalalag
Ia lbe well, IIJII .. Ilatcrval, latarwlo of Clll!as porfimllloaa, aad dcptba aad
in>" of60 mabulala ......
II. DATE WELL AIIANDONED ..:9;:.;/3}::.0:;;9:..... _____ _
&lON4TUREOFPRIVATEWELLOWMBilAIIANDONINGTB&WELL DATB
(l"bc pdmc weD--ba ac bldlvldual wbc IIDIIIIlii!J.-hlllllarRIIdaald wall
bu=nlaocc with UA NCAC 2C .DII3J
Gary Fischer
PllllmiD NAME OP PERSON ABANDDNINDTBE WELL
Submit a copy ta the awner aad the arlglaal to tbe Dlvllloa orWaler Quollty wllhlD 30 day a. F111111 aw.ao
Rev. 51011 Atta; lnrornuatlaa Maaagemeo&. 1617 MaU Senlce Cauter -llalelgb, NC 2.7699-1611, Pboae No. (J19J 733-7015ut 561.
,e-e.,s
~~J f7!r/
;/)1l1jt-·,
"t:t:-0 ~J~V
e-c-JI::.
J I /,SI)
w-~S
· 1nl rJe .•
,f-0
1-----:-1. v t Sl?)
]tid "'e
{/J~) f./-"1 W lJOOR•~ ruuo
sa<Lt1 pua Slpdap puu .. ~d 8upa:1 JO ll{liiU:Il!IJ
'(IIAmiiiJ (alllllll 'flaJA"''lii! l!IJ!li!B=J stma.tJS
JO .IDiliiU8!JI p1111 tpdap 'qtdop (11101 BU!JAOqu QllJA
B !1119 I a1111 •
; i 11• I· 1
1(1 • 1 111•1 ll:a•~•·•lf·H
S! ·=~·111 11 1 1'1 llllifl lit·
891!19 EI9CDBB891UIOI!IO
'
WELL ABANDONMENT BECOBD
North Carolina Dcplll'lmellt of Environment and Natuml Rcsoan:cs-Division of Water Quo lily
WELLCONTRACTORCERTIHCATI~O~N~#~33~3~9~============~-------------,
1. WELLCONTRACfOR:
Gary Fischer
WeD Coolnu:lor (ladlvldual) Name
Mld-AUanUc Associates, Inc.
Well CaalnU:Iar Company Nama
S"!liE8T ADDRI!SS 409 Rogers VIew Court
Raleigh NC 27610
Cloy orTowa SOliD Zip Cadc
~.25D-9918
Ala. codo • Pbooa aumbcr
2. WELL llll'ORMATION:
SITI! WELL m # 0fappUcable)1.::M::;Wc:.·...:1...:4 _______ _
STATI!WELLPERMITf(ifappllcablc).:.:NA::.:.... ______ _
C01JNTYWELLPERMITf0fappUcablc•>c.N.::A..:..... ____ _
DWQ er OTHER PERMITf (lfappUcablc'l.l; NA=-------
WELL US£ (Cbcck appUcablc ... ): Ill Moaltorlag 0 RaldeoUal
0 Mualdpal/PabUc 0 lnduatrlai/Cooua....W 0 Agrlcaltural
0 Reconcy 0 IDJccUoa 0 lrrlgadea
00ibar(liltuae) ____________ _
3. WELL LOCATION:
COIJNIY Iredell QUADRANGLE NAMB ____ _
NI!ARI!STTOWN:.=M~oo~re~s.:.:~~~~e~--------
(SinZI/Raod-N ....... "'""'"'oalty,Subdlvfslao. La1 Ne.,l'1ucol.Zip c:.de)
TOPOGRAPHIC I LAND SI!TI"ING:
Ill Slopa 0 Vallay 0 Pint 0 Rldp 0 Olbcr'-------
(Cbcck OJIPI'III'iato aeiiiDg)
1.\Tll"UDE ~ 35.675::6:::9c.._ __ _
LONGII"UDB W 80.81:..:8:::37.:.._ __ _
Maybolc ......... ~ 1eccmdl, or Ia a
daolmollb"""
LaUtadclloa&lluda ,. • ..., 1Z1 GPS OTopograpblc 11111p
(Lor:atlon of well must 6to 1/:own on a IJSOII topa map and
allrl<h<d to thbfbm If not wing GNJ.)
4a. FACJLriY .. 1ba DBm11 aCibD basf=u wbm lbawcllllloeulad. Complela 4a aad4b.
IICo-...Joi...U. ddp4o; ....,lola4b. wall OWIICI'Ialbmoodeoaoly.)
FACILITYIDf(lfoppllcohlc) NA
NAMB OP PACllJTYMOOre-=sv~lli;-:la:-;M:-;I;;;IIB::-------
S"!liEBT ADDRI!SS 4 76 South Main Street
Mooresville NC 28115
Cloy orTowu Smm Zip Cadc
4b. CONTACf P£R60NIWELL OWNER:
NAME Cherokee Investment Services, Inc.
S"!liE8T ADDRESS 111 E Hargett Street Suite 300
1b f\JC. .;!'l 0
&. WELLDBTAIL&:
o. TDIIII Doplb: 42 11. Dlcmeler: 2 io.
b. Waler Lcwl (Below Mcalarlog PolcQ: 28.00 11.
-...ms point is 0 II. obaw llllld IIUI"thco.
1i. CASINGt ~ Diameter
o. C1111aa Dcptb Ofkuowa): 27 11. 2 in.
b. Culagllemoved: 0.25 11. ~ Jo.
7. DISINRCTION: .:.NA::..:...---:---
(AmDUDI or fiS%. 7"' calcium hypocblodm uacdl
B. SEALJNGMATI!RIAL:
NrN Q:mrnt
C.mea'Tt :o27:......_lb.
Wol!:r I gal
llmllmlla
Baalaaim ). lb.
Type: Ill Sluny OPallcll
Wolar gal
Sgnd Ccmmt
Wlw:.
~maiCrlai.:.N~A=---------------­
~.:.N~A~--------------
'· EXPLAIN METHOD OF EMPLACEMENT OF MATI!RIAL:
S!arfaca POl rr Method
10. WELL DIAGRAM: Drowadctoilcdllmld:oflbewaUoo lbebackoftbis
lbrm obawias tolal doptb. clcptb eod dlomelar ar ,.....,. (If aay) n:malalas
Ia tbc well, IP"Wl ialo:mll, Ia.....,. ofcaaias perlb:ad001o eod dcplbe eod
lypol or 6U ......W. .. ol.
11. DATI! WELL ABANDONED ..::9:::131::.0=9::..._ _____ _
SICINATIJIIE OV PRIVATE WELL OWNERAIL\II"DONINO TilE WELL DATE
(lbopdvalo...U""""-b' .. -wlloiiOIIlllllllx ___ ...u
la.......WU:.wllb ISANCAC2C .0113.)
Gary Fischer
PRINTED NAMB OV PERSON ABANDONING TilE WBLL
Submit a a~py to the owaer and tho ori&lnal to tho Dlvblon atWater Quality within 30 daya. Fo:u:GW-.10
Rov • .5106 AUn:loformadea Mooegomea~ 1617 MaD Sarvlce Coutu-Raldgb, NC l76g!l-11i17, Pbooe No.!'l!J) 733-7015 ut 5611.
EJ
well showingmlal deplh, depth and diameter of
scn:eos 111111aining in tho wall, gravolioterval,
intorvals of casing perfol'llliom, and depths and types
of fill materials used.
a"' filL c 65i"'1
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flt w -IV (r11tt. ./t}
fi&/,·C~­
/) -1(?.-'