Buncombe_Well Abandonment_20220817

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WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
2194-A
CONTRA,C,TPy.C:ER-KJF ATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
CLYDE SAWYERS A,IJr ! 2�2Z ..Total Depth 8O5 ft. Diameter:6 1/8 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): ft.
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CLYDE SAWYERS AND SON WELL DRIUUd!�F(�'A�Id�p p{JhY1P"IIG Measuring point is ft above land surface.
a
Well Contractor Company Name
14885 NC 209 HWY 6. CASING: Length Diameter
Street Address
HOT SPRINGS NC 28743 a.Casing Depth(if known): UNKNOWN ft. in.
City or Town State Zip Code b.Casing Removed: ft. n.
8( 28 ) 665-2022 CHLORINE
Area code Phone number : 7. DISINFECTION:
2.WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
SITE WELL ID# (if applicable) $• SEALING MATERIAL:
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement Ib. Cement lb.
COUNTY WELL PERMIT #(if applicable)
2022-00284 Water gal. Water aal.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite lb.
WELL USE (Check applicable use)E Monitoring V Residential
Type:C Slurry C Pellets
❑ M unicipal/Public ❑ Industrial/Commercial = Agricultural Water gal.
❑ Recovery ❑ Injection C Irrigation Other
❑ Other(list use) Type material POURED CEMENT
3.WELL LOCATION: Amount 3 112 YARDS
COUNTYBUNCOMBE QUADRANGLE NAME
NEAREST TOWN: ARDEN ; 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
PUMPED CONRETE FROM CONCRETE
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) : TRUCK
TOPOGRAPHC/LAND SETTING:
F1 Slope F1 Valley p Flat F RidgeF Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of thmell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 36 "DMS OR 3X.XXXXX PDD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 75 °_' "DMS OR 7X.XXXXXXX=D types of fill materialsised
Latitude/longitude source: ❑GPS []Topographic map 07-07-2022
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a THIS RECO D S BEE POVIDED O TH ILL OWNER.
(If a residential well,skip 4a;complete 41b,well owner information only.)
FACILITY ID# (if applicable) 07-07-2022
NAME OF FACILITY SIG uR F CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELU OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an"individual ersonall bandons his/her residential well
in accordance with 15A NCAC 2C.0113.)
4b.CONTACT PERSONfWELL OWNER:
NAME BARBARA LEICHT PRINTED NAME OF PERSON ABANDONING THE WE ILL
STREETADDRESS23 RACING LANE
5ubmrt a cop Form GW-30 oLVSW' ofyto rnt
1617 Mall.Servtce Center,Raleigh,_NC 27699 1617,Phone (919,)807-630Q Rev.5110