Catawba_Well Abandonment_20220930 (2)

WELL ABANDONMENT RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# Q-AG- 1 '-
1.WELL CONTRACTOR: 5. WELL DETAILS:
-- , • �� Ai=, � �� o J-2 a.TotalDepth—/Aft. Diameter in.
Well Contractor(Individual Name b.Water Level(Below Measuring Point): q 7/' fL
t� M yes4m S , Measuring point ie ft.above land surface.
Well Contractor Company Neme
8. CASING: Length Diameter
Street Address T-
- r�l AeAli e?I k S C_,� ' 'a k a.Casing Depth(If known): ��fL in.
c�Cffy-or Town State Zip Code b.Casing Removed: C1-r_s fL �—In.
T �q ' 7. DISINFECTION: d'ri`"L"J
Area code Phone number _
2.WELL INFORMATION: (Amount of 65%757.calcium hypochlorite used)
SITE WELL ID# (If applicable) - S. SEALING MATERIAL:
Hr y'STATE WELL PERMIT# (if applicable) Neat Mament &=damaDt Orf�ZOZZ��l u�Ja
Cement b. Cement fib.
COUNTY WELL PERMIT #ire}' Water gal. Water — aa1.
Bantonite
DWQ or OTHER PERMIT #(ff applicable L ,
WELL USE(Check applicable use)'? Monitoring eslddritlat: .�..
:. 1ype:❑Slurry el9'p filets
❑ M unlelpal/Pablie � Industrial/Commercial iJ Agriculture F p Q 0 2022 Water gal.l' b4l- J ��
❑ Recovery ❑ Injection ❑ Irrigation er
❑Other(list use) r;yd'Qi_3-aG
Type matrial _
3.WELL LOCATION: Amount
COUNTY G/Al'AJ4.* QUADRAN IE NA
NEAREST TOWN: c l GG S. EXPLAIN~METHOD OF EMPLACEMENT OF MATERIAL:
i
(Shest/Road Name,Number,Community,SubdMsion,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTI
NG-
0 Slope ❑Valley ❑ Flat Other
(Check appropriate setting) 10. WELL DIAGRAM :Drawl a detailed sketch of thes0 on the back of this
form showind total depth;depth and diameter of screens(if any)remaining
LATITUDE 6 °1L 'S���PZDMS OR 3X.XXXXU-X—Y DD in the well,grave!interval,intervals of casing perforations,and depths and
LONGITUDE75M°& DMS OR 7X.XXXX M_=D types of fill materiatmed
Latittudellongituda scrface: PS Oropographic map
(location of well must be shown on a USGS topo map andettached to 11. DATE WELL ABANDONED ZZ
this form if not using GPS)
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15ANCAC2C,WELJL-CON5TRt1CTtQN STANDARDS,AND THAT A COPY OF
48.FACILITY-The name of the business where the well is located.Complete 4a THIS R H B PBVID 0 E OWNER.
(If a residential well,skip 4a;co to 4b,well owner infonnetion only.)
FACILITY ID#(if appif ;a Go ; ��
NAME OF FACILITY / 1 AT R F CERTIFIED LL ONTRACTDR DATE !!//
STRE- ADDRESS '71_ � PAlad�
5; l/ \ GNATURE OF PRIVATE WELUOWNER ABANDONING THE WELL DATE
City or Town State( Zip Code (The private well owner must be an indMdual wkMollipbandons his/her residential wen
4b.CONTACT S�
in accordance iilh 16A NCAC 2C.0113.)
ERSONNVELL OW�N� • r
w
NAME 1� G �i"/„c G�'Ci
_ PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS !. Wr-iM.- lilt: e2
-Submit a copy to the o owner a th and wd'ltg G r a: ivis on of Water Quality-information Processing, For,GW-30
1617 Mall Service Center,Raleigh,NC 27699.16117,Phone:(919)It07.6300 Rev.5/10

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