WQ0000550_Well #2 Abandonment Record_20220221

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1. WELL CONTRACTOR:
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # "t Li(, G
Contractor
ndt` 74e7Ca' -Ceti
Well vtdual) Name
Ida 11\ ate kecsd LicU c' Mt (13
Well Contractor Company Name
j 61/45CtL o v .
Street Address
rs.)l\d‘G c 27 q 7 7
City or Town
?fl) 0.401/4k
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # Of applicable) et;2,,
STATE WELL PERMIT # (if applicable)
State Zip Code
COUNTY WELL PERMIT # (if applicable) 1' ' r 7
DWG or OTHER PERMIT # (if applicable)
WELL USE (Check applicable useifce onitaring Residential
M unicipaUPublic [ Industrial/Commercial al Agricultural
Recovery Injection Irrigation
Other (list use)
3_ WELL LOCATION:
COUNTY 6.4.MS44.14SUADRANGE NAME It
NEAREST TOWN: 0149
441 KIWI& Rd.• f t c. a7'jflc
(Street/Road Name, Number, Community. Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
I. Slope L Valley ?fiat RidgeL Other
(Check appropriate setting)
LATITUDE 3 c, MI5 OR DD
LONGITUDE c rf et 3 8S"" DMS OR
Latitudetiongitude source: (BPS fl opographic map
(location of well must be shown on a USGS topo map andattached to
this fort if not using GPS)
DD
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) at 2 j
NAME OF FACILITYle Lasackesmeiclosk OmuirsIGNA 71F. WELL CONTRACTOR ATE
STREET ADDRESS Li ti Lk kck e
s. WELL DETAILS: !-
a_Tota! Depth .0 f�40 ft_ Diameter: e
in.
b. Water Level (Below Measuring Point): (a. r ft.
Measuring point is 3 ft. above land surface.
6. CASING:
a. Casing Depth Of known):
b_ Casing Removed: b ft. t>
Length Diameter
7_ DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement Ib.
Water gal.
Bentonite
Bentonite.
Type: _. Slurry
Water
Other
Type material
Amount
Sand Cement
Cement
Water
tz
Ib_
gal.
9. EXPLAIN ME-11-100 OF EMPLACEMENT OF MATERIAL;
C i OC AgM t Lw ( 6TR
p cec i"Mki-
in.
in.
j p
r8c )
• 10. WELL DIAGRAM : Draw a detailed sketch of Dwell 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 materialsised
11. DATE WELL ABANDONED
211112.2
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS ' EEN P®ViDED TO THE WELL OWNER.
City otTown State Zip Code
4b. CONTA T P RSONtiWELL OWNER:
NAME r'4, t5&
STREET ADDRESS 144, MNp k lZ M4pl2 A)C
ff� st
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone]
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual wpersonatl)abandons hislher residential well
in accordace with 15A NCAG 2G .0113.)
axe -
PRINTED NAME OF PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5/10