Rockingham_Well Abandonment_20220621

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# :, -&
1.WELL CONTRACTOR: 5. WELL DETAILS:
•J n(1 n PA .�( f� Sjl� i.`�4t a.Total Depth:_ ft. Diameter lk in.
Well Contractor(Individual)Name C b.Water Level(Below Measuring Point): _ft.
=l�>M1 i J/�� J � A ��/' ��Q•�hc, Measuring is�_ft.above land surface.
Well Contractor Company Nafne
STREET ADDRESS Q� b�� /'� [�/�K z/ �� 6. CASING: Length Diameter
/
�/✓ 1 a- J-7 99 4 7 a.Casing Depth(if known): _A /P- ft. T A in.
—Town State Zip Code b.Casing Removed: 4,4- _ft. /1/'+ in.
(33 - LI,- 7- y N�.. (r yp
Area code-Phone number 7. DISINFECTION: r�r' - 7 5
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ED#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable) "a?_2 2 P 5-U/ Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ❑ Monitoring X Residential Bentonite lb.
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural Type:❑Slurry ❑Pellets
Water gal.
ElRecovery ElInjection ❑ Irrigation
Other
❑Other(list use)
Type material Cd M 19 LLG G�J"
3.WELL LOCATION: Amount
COUNTY �0� �UADRANGLEnNAME
NEAREST TOWN: /A CL 1 f9 (0-w 9, EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision.Lot No.,Parcel,Zip Code) Fn.// "J n le—, C p yyt,��,L(i— C
8 .jtw y
TOPOGRAPHIC/LAND SETTING: —d Ce ,_e•
❑Slope []Valley Flat ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE Maybe in coed degees,
/ty(4 '�' ' minutes,seconds,ar in a form showing total depth,depth and diameter of screens(if any)remaining
t decimal format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDES 0 types of fill materials used.
Latitude/longitude source: ;KGPS ❑Topographic map
(Location of well must be shown on a USGS topo snap and 11. DATE WELL ABANDONED - � Z
attached to thisform ifnot usingGPS.)
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
42.FACILITY-The name of the business where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,sldp 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) r�
NAME OF FACILITY 2 . ! /�� rIn D/Ju'^. L L Z
SIGNATUR P OF C TIFIED WELL CONTRACT y DATE
STREET ADDRESS
11971 / t4. a- v �- UN
E ?Qz?
City or Town 'State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDbIVIN 4 E W-ELL DATE
(The private well owner tout be an individualtA— e"tall jl n(i iAr i irysidep ]well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0113.)
NAME h t /7 I r, h. (( � k
STREET ADDRE S IC' 71 /j 11 7f`wj 12 PRINTED NAME OF fERSON ABANDONING THE WELL
•G-
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Forth GW 30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] eat 568. Rev.5/06