WQ0000550_Well #4 Abandonment Record_20220221

WELL A
ANDONMENT RECO
l.,
III
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # W % (9 G
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
.� �1~c }caU1/45 c \�Csit c \\t
Well Contractor Company Name
Street Address
CibNA\
City or Town State
1\t c Ti ger?
can) -92 . , yay
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable)
Zip Code
STATE WELL PERMIT # (if applicable) la s—
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
12S-?
WELL USE (Check applicable use): nitoring _ Residential
M unicipatlPublic industriat!Comrnercial Agricultural
Recovery T Injection 7 irrigation
_ Other (list use)
3. WELL LOCATION:
COUNTY 6.0stt *S4L 'QUADRANGLE NAME IJ C4 pk
NEAREST TOWN: " 4 rGt
4Li44 Mkt Ryl r Mccpk. t AJ C 27c5—%
(Street/Road Name, Number. Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SE I I ING:
Slope L Valley _✓Aat _ Ridge[J Other
(Check appropriate setting)
LATITUDE '4 ° tSC 19 " DMS OR DO
LONGITUDE (LC ° LIB' ti 3 " DMS OR , DD
Latitude/longitude source:.ePS Q%pographic map
(location of well must be shown on a USGS topo map andattached to
this fonn 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
STREET ADDRESS 44k lincte t Y
Meth It_ QC, aid 4S-6
City Town State
4b. CONTACT PkRSONIWELL OWNER:
NAME Qoa ¥"kAbk\
Zip Code
STREET ADDRESS 44K tAGPk &.. v' ►jk ij ce
a7U e
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]
5. WELL DETAILS:
a.Total Depth 4
ft. Diameter. 2
b. Water Level (Below Measuring Point): '7 ft.
Measuring point is 3 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
Length Diameter
ft.
to ft_
7. DISINFECTION: b\ T h\
(Amount of 65%75% calcium hypochiorite used)
8. SEALING MATERIAL:
f..
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite Ib.
Type::=, Slurry :✓Pellets
Water gal.
Other
Type material
Amount
in.
a in.
Sand Cement
Cement
Water
lb.
gal.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
L) e•-1\ LN1 ( 41TH
� h 1,0 t r` Ct.
Cie 14CS leatAkanik 100Aap
in.
10. WELL DIAGRAM : Draw a detailed sketch of Meett 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 materiatsised
11. DATE WELL ABANDONED
I 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 PEVIDED TO THE WELL OWNER_
tGNATURE OF CERT1'ij. D WELL CONTRACTOR
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual wpersonallyabandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
ct\D e ek 1,1
NAME OF PERSON AB N
PRINTED•
DOLING THE WE LL
Forrn GW-30
Rev_ 5/10