Iredell_Well Abandonment_20220805

-►�, ,•xMMLL AMM-OlITNYL+M RECORD
+I r North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTMCATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth—�Lft. Diameter. h In.
Well Contractor(individuaq Name b.Water Level 1 (Below Measuring PolM): It
C. a.-J t ��11111e, +�m1ac�-rNt�vrT S , Measuring point Is ft,above and surface,
Well Contractor Company Name
CR ��'"='ti+_ -A M 1)d. L of S. CAGING: Length Diameter
StmetAddress q
a � a.Casing Depth pfknown): _ft. In.
C�orTown State- Zip Code b.Casing Removed: �_ft. In.
Area code Phone number 7. DISINFECTION: lL dam_
2.WELL INFORMATION: (Amount of 65%759/8 calcium hypochlorite used)
SITE WELL ID# (if applicable ®. SEALING MATERIAL:
Neat
STATE WELL PERMIT# (if applicable) CaMent SaDd.1:emt
n Cement Cement__lb.
COUNTY WELL PERMIT #(if applicable) ' !p` Water gal. Water dal,
DWQ or OTHER PERMIT #fdapplicable) ® ton e!�
WELL USE(Check applioeble use)�l Monitoring esiderltlal Bentonite pC�/0A' f
Type:❑Slurry ellets /f7 I
❑ M unicipalfPublic ❑ IndustriallCommercial ❑ Agricultural ,'� ater gal, •t d r'� �/
❑ Recovery i7 Injection LI Irrigation y"`�, `� Other
0 Other gist use) 2022
Type materialG�i�
a.WELL LOCH N Intcramzat+-�i'r'"'gig UAcunt L;`3 y� l
COON CI QUADRANGiE NAME
NEAREST TOWN: 9. EXPLAIN"METHOD OF EMPLACEMENT OF MATERIAL:
- (Street/Raad Name,Number,Community,Subdivlelon,Lot No.,Parcel,Zip Code) � . ..
TOPOGRAPNC/LAND SNG:
G Slope 0 Valley flat 0 Ridge❑Other
(Check appropriate setting) 10. WELL DIAGRAM Drat a detal!ed sk * ,����� .c.c�r o,4,.�>!ar,�e�cle afthis
LATrI,UDE 6 form showind total depth,depth and diameter of screens of any)remaining
DMS OR 3X.XXXXXXXXlOp In the well,gravel interval,Intervals of casing perforations,and depths and
LONGITUDES'p r �MS OR 7X.XXXX=tM_=D Was of fill materfalsmsed
Latitudefiongitude source: ffirps propographic map
(location of well must be shown on a USGS topo map andefteched to 11. DATE WELL ABANDONED
this fbnn if not using GPS)
100 HEREBY CERTIFY THAT THIS VVELL WAS ABANDO IN ACCORDANCE
WITH 15A NCAC 20,WELLCONSVRN�CTI N STANDARDS.AND THAT A COPY OF
48.FACILITY-The name of the business where the well is located.Complete 4e o THIS R H S Bl: PRVID 0 E LL OWNER(if a residential we@,skip 4s;complete 4b,well owner information only.)
FACILITY ID#(if applicable)
NAME OF FACILITY i A URE.F CERTIFIED ELL ONTRACTOR
STREET ADDRESS
UNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner rust be an lndlviduat u @BamUpbandons his/her maidedet well
4b.CONTACT PER5SO DWELL OWNER: /,fA in accordance with 16A NCAC 2C.0113.)
NAME !�_I/lj� PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS ' 5�ew w'
Submit a copy to the owner and the original tag:nild, ton o ater 4taallty-Information(Processing, Form GW-30
1617 Mail Service Center,Raleigh,NC 27699.1617,Phone:[phone] Rev.5/10

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