WQ0000550_Well #3 Abandonment Record_20220221

WELL A
ANDONMENT "ECOR
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # LI 4 G6 -
1_ V51. CONTRACTOR:
nuke Ccts t
Well Contractor (Individual) game
./3\11\CAok\ft.Chol L1•6\gdk C1/4 \LIN‘3
Well Contractor Company Name
733 (pig1tl% ';)c••
Street Address
C A\c,, 1 C 'fet 77
City or Town State Zip Code
( 9-r).) 7 3-2 2'
Area code Phone number
2. WELL INFORMATION:
SiTE WELL ID # (if applicable) ..3
STATE WELL PERMIT # (if applicable) Y 2.S47
COUNTY WELL PERMIT # (if applicable) a S'" 7
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)1SMonitoring - Residential
M unicipallPublic Industrial/Commercial Agricultural
-11 Recovery ^ injection 17 Irrigation
Other (list use)
3. WELL LOCATION:
COUNTY CSt.,-,C` Z1/4 bt-ZQUADRANGLE NAME
NEAREST TOWN_ nil l p t-c
4t t 1ccples a�cise
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
_ Slope D Valley areget RidgeLi Other
(Check appropriate setting)
LATITUDE 3 C _° �.7j' t3 9 " DMS OR DD
LONGITUDE _03 Ca° fitDMS OR DD
Latitudeliongitude source: 1 PS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this fbmr if not using GPS)
s
M
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 netisek cdiC_' - k •44v
STREET ADDRESS �{ 4 k tc t L
in a le N.)L 7715- 4
City or Town State Zip Code
4b. CONTACT PERSONNVELL OWNER:
NAME RCA kk0 WC, t
STREET ADDRESS Q t{ Lk nide Lc_ gicin
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]
Length Diameter
e� ft.
0 ft_ o
5. WELL DETAILS:
a.Total Depth /2® ft. Diameter: a. in.
b. Water Level (Below Measuring Point): S 6 ft.
Measuring point is 3 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
7. DISINFECTION:
(Amount of 65°1075% calcium hypochiorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Sand Cement
Cement
Water
Ib.
qat.
Bentonite
o Bentonite )b.
Type: L. Slurry :_ Pettets
Water ce beadgal.
Other
Type material
Amount
9. EXPLAIN METHOD OF EMPLACEMENT F MATERIAL:
in.
in.
&cm, twrzint, tit) Ace
10. WELL DIAGRAM : Draw a detailed sketch of bell 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
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECOR ri r BEEN P®VIDEO TO THE WEIL OWNER_
_Ab ,2 a
SIGNATU "F ►k- TIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(1 he private well owner must be an individual i-vhersonalhebandons his/her residential well
in accordance with 15A (N�CCAC 2C .0113.)
PRINTED NAME F PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5/10