WI0100006_WellAbandonment_20170511

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xt y WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
= WELL CONTRACTOR CERTIFICATION# 2- 1 1
1.WELL CONTRACTOR: 5. WELL DETAILS:
a_Total Depth: 4 0 ft- Diameter: 4/c in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point):___C-Cle ft.
- R jd: --��� � Measuring point is ®_ ft.above Land surface.
Well Contractor Company Name
STRREETT�A�DDRESSS l.3'1/�lZ/r �( , 6. CASING: Length Diameter
•z a.Casing Depth(if known): R. in.
City or Town State Zip Code b.Casing Removed: ft. in.
Area code-Phone number 7. DISINFECTION: 12, e 7-
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable)XIII 10100 0C(© Neat Cement Sand Cement
Cement lb_ Cement lb.
COUNTY WELL PERMIT#(if applicable) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Circle applicable use): Monitoring Residential
Alunicipal/Pub' dustriat/Commercial Agricultural Bentonite lb.
Type:Slurry_Pellets_
Recovery flikiection j Irrigation Water gal.
Other(list use) _ _
Other
3.WELL L04CATIO CC VC— t�b y
d
COUNTY 1�1 ' QUADRANGLE NAME Type material
NEAREST TOWN: j�/0f1f- W-•C-Ar, Amount 3 (/i_j
/f I COO kf th 1,16 Ch 44-a L ya E
(StreetlRoad Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TO RAPHIC/LAND SETTING: .
Sloe Valley Flat Ridge Other
(Circle appropriate setting)
LATITUDE May be in degrees,
minutes,seconds,or in a
�P
LONGITUDE ��r 1,7V� ��4-1decimal format 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back oftttis
Latitude/longitude source: G S Topographic map form showing total depth,depth and diameter of screens(if any)remaining
(Location of well must be shown on a USGS taro map and in the well,gravel interval,intervals of casing perforations,and depths and
attached to this form if not using GPS.) types of fill materials used.
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. r
(If a residential well,skip 4a;complete 4b,well owner information only.) 11. DATE WELL ABANDONED b r
FACILITY ID#(if applicable)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY WITH 15A NCAC.2C,WELL CON TRUCTION STANDARDS,AND THAT A COPY OF
THIS RECORD HAS EN PRO ED TO THE WELL OWNER.
STREET ADDRESS
City or Town State Zip Code SfGfqATtJo OF CERTIFIED WELL CONTRACTOR DATE
4b.CONTACT PERSONtWELL OWNER.
NAME -:02 4/Vt.1 F /"�L' JJ�t/ _I SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
STREET ADDRESS IH I C"vl�tl Q �� (The private well owner must be an individual who personally abandons his/her residential well
tl td in accordance with 15A NCAC 2C-0113.)
City or Town State Zip Code PRINTED NAME OF PERSON ABANDONING THE WELL
&f.t )- 29 = 9;0g3
Area code-Phone number
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 276994617, Phone No.[phone] ext 568. Rev.5/06