GW1-2021-03049_Well Construction - GW1_20210527

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WELL ABANDONMENT RECORD
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No1rth Carolina Department of Environment and Natural Resources-Division Water
WELL CONTRACTOR CERTIFICATION# 3519.A DV,rR Ssc4ion
1.WELL CONTRACTOR: 5. WELL DETAILS:
Robby G Phillips a.Total Depth: 35'' ft. Diameter: 24 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 91611 ft.
Pearson Pump Sales & Service, Inc Measuring point is 0 ft.above land surface.
Well Contractor Company Name
STREET ADDRESS 2400 N William Street 6. CASING: Length Diameter
Goldsboro NC 27530 a.Casing Depth(if kno„vn): 35 ft 24 in.
City or Town State Zip Code b.Casing Removed: 5' 6" ft. —�in.
919 - 734-4267
Area code-Phone number 7. DISIi\'FECTION: . 1/2 Ib.
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(ifapplicable) N/A 8. SEALING MATERIAL:
STATE WELL PERMIT#(ifapplicable) N/A Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(ifapplicable) N/A
Water ! gal. Water gal.
DWQ or OTHER PERMIT#(ifapplicable) N/A Bentonite
WELL USE(Circle applicable use): Monitoring Residential
Municipal/Public Industrial/Commercial Agricultural Bentonite lb.
Recovery Injection Irrigation Type:Slurry_Pellets_
Other(list use) Water gal.
Other
3.WELL LOCATION:
COUNTY Johnston QUADRANGLE NAME Type material Dry Clay
NEAREST TOWN: Princeton Amount Compacted Clay From 4' to 35'
Massy Holt Road
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TOPOGRAPHIC/LAND SETTING: Remove 5'6"Top Casing. Dewater Well To 35',
Slope valley VPlat Ridge Other Install Chlorine, Fill Hole With Dry Clay In 5'Lifts And
(Circle appropriate setting) - .`('ompa .t Po 1r 'Cement On Top Of Fxisting Well
N 35 .41383 May be in degrees. Casing Covey Remainder Of Hole With Dirt Fill
LATITUDE _ _ minutes,seconds,or in a
LONGITUDE W 78 .161188 decimal format 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
Latitude/longitude source: -IGPS Topographic map form showing total depth,depth and diameter of screens(ifany)remaining
(Location ofwell must be shown on a USGStopo map-and in the well,gravel interval,intervals of casing perforations,and depths and
attached to this form if not using CPS.) types of fill materials used.
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b. A—2021
(Ifa residential well,skip 4n;complete 4b,well owner information only.) IL DATE WELL ABANDONED 5-14
FACILITY ID#(ifapplicable) NSA 160 HEREBY CERTIFY THAT.THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY N/A WITH 15A CAC ,W LC STRUCTION STANDARDS,%AND THAT A COPY OF
THIS S BE P VI O THE WELL OWNER.
STREET ADDRESS NIA
3519-A 5-14-2021
City or Town State_ Zip Code SI AYU Ilf OF C VITIFIED 4WELL CONTRACTOR DATE
4b.CONTACT PERSON/WELL OWNER:
NAME J&N Developers SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
501 S Pearl Street (The private well owner must berm individual who personally abandons his/her residential well
STREET ADDRESS in accordance with 15A NCAC 2C.0113.)
Princeton NC 27569 Robby Phillips : 35.19-A
City or Town State Zip Code PRINTED NAME OF PERSON?ABANDONING THE WELL
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 27699-1617, Phone No.[phone] ext 568. Rev.S106
F

0'
Fill Dirt 3'-6" 6"
- - - - - - - - - - - - - - 1
Cement
Clay
35'