WQ0000550_Well #1 Abandonment Record_20220221

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1. WELL CONTRACTOR:
Well Contractor (Individual) Nbme
tti \Vat Vgge-AC dit c3 N t\b
Well Contractor Company Name
33 CSCe k 0
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # �{ Li (06 6
Street Address
(Ito rtX\s % C
City or Town
f2 ) 722 2Li0i
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
State Zip Code
STATE WELL PERMIT # (if applicable) 12 r- 7
COUNTY WELL PERMIT # (if applicable) is— 7
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)onitoring 1 Residential
M unicipailPublic 1 Industrial/Commercial T Agricultural
Recovery 7 Injection • Irrigation
Other (list use)
3. WELL LOCATION:
COUNTY ii., eC QUADRANGIE NAME cRetkAt__
NEAREST TOWN: in (A? Imo_.
Litt Oncuilk kat 2flWs't
(Street/Road Name. Number, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
Slope G Valley ` of at Ridge[; Other
(Check appropriate setting)
LATITUDE 034 o 4 3
DMS OR
LONGITUDE ©fir. CA' rt DMS OR
Latitudellongitude source: BPS Qropographic map
(location of well must be shown on a USGS topo map andattacherl to
this farm if not using GPS)
4a- FACILITY - The name of the business where the well is located. Complete 4a
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY
Ate ()ce ' kr'e $- wk Otot
STREET ADDRESS
City or Town
State Zip Code
4b. CONTACT,PEERSONIWELL OWNER:
y
NAME { .ta I-i Ce1/4D
DD
DD
5. WELL DETAILS:
a.Total Depth 1‘ ft_ Diameter: a. in.
b. Water Level (Below Measuring Point): 1 ft.
Measuring point is 3 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
7_ DISINFECTION:l
Length Diameter
°? f_ _
ft_
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement Ib.
Water gal.
Bentonite
Bentonite lb.
Type: Slurry ` Pellets
Water gal.
Other
Type materiat
Amount
Sand Cement
Cement
Water
lb.
gat.
9. EXPLAIN METHOD OF EMPLL EMENT OF MATERIAL:
in.
in.
ptacce J V6e.tl1fro tia.i Je_ c(elcwN A
9
10. WELL DIAGRAM : Draw a detailed sketch of till on the back! of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialslsedd
11. DATE WELL ABANDONED
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2G, WELL CONSTRUCTION! STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PIWIDED TO THE WELL OWNER_
C : .-TIFIED WELL CONTRACTOR
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
: (The private well owner must be an individual w}tarsonalhabandons his/her residential well
: in accordance with 15A NCAC 2C .0113.)
646, 6
: PRINTED NAME OF PERSONABANDONING THE WE LL
STREET ADDRE$ s 4 4( linty IA_ p NC
4 re
Submit a copy to the owner and the original to: Division of Water Quality - information Processing,
1 G17 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone]
Form GW-30
Rev_ 5/10