Alexander_Well Abandonment_20221014

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WELL ABANDONMENT RECORD j
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# l
1.WELL CONTRACTOR: S. WELL DETAILS: f
a.Total Depth 32 ft' iameter.24 in.D
Well Contractor(Individual)Name b.Water Level(Below Measuring Point):28 ft.
Measuring point is 0 ft.above land surface.
Well Contractor Company Name
S. CASING: i Length Diameter
Street Address
a.Casing Depth(if known): ft. in.
13 24
City or Town ;. State' Zip Code b.Casing Removed: ft. in.
Area code Phone number 7. DISINFECTIOIU`;' "/ � �CN®-
'(Amount of.65%759/6 calcium hypochlorite'used)
2.WELL INFORMATION: — f 1
8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement lb. Cement lb.
COUNTY.WELL PERMIT #(if applicable) Water gal. Water oal.
Benionite c
DWQ or OTHER PERMIT #(if applicable) ti y t_; 5
Bentonite, lb.WELL•.USE(Check applicable use)El, Monitoring 91 Residential Q C T 1 4 2022
Type:❑Slurry ❑Pellets ;
❑ M unicipaUPublic ❑ IndustrialICommercial ,O.,Agricultural Water gal,
)r1i'ui'tet�E0 1 "i Un'rl
0 Recovery ❑ Injection ❑ Irrigation Other r,%, 1V 0G
❑ Other(list use) Type material Gay soil up to the top of the Casing
Amotnt a L2
3.WELL LOCATION:
COUNTY Alexander QUADRANGLE NAME
NEAREST TOWN: Bethlehem 9. EXPLAIN METHOD OF EMPLACEMENTOF MATERIAL:
bueke
(Street/Road Name,Number;Community,Subdivision,Lot No.,Parcel,Zip Code)
ee
TOPOGRAPHC/LAND SETTING: .
VSlope ❑Valley ❑ Flat ❑ Ridge❑Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE _35_ _'49 0.0000 "OMS OR DD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 81 16 50.000D DMS OR DD types of fill materiaisrsed
Latitude/longitude source: OGPS E]Topographic map
(location of well must be shown on a USGS topo map andattached to 11.DAT�E WELL'ABAN� DONED-) D/ y
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 RECORD HAS BEEN PBVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable)
NAME OF FACILITY : SIGNATURE OF CERTIFIED WELL CONTRACTOR DA
STREET ADDRESS ' 7a9
SIGNATURErOF R NATEiWEL'LeOW ABANDONING THE WELLD TE K
City or Town State Zip Code he•privatewell'ow15e Nust`beanmdi` ua� �ersonall bandonshisfiet- sidentiawell=
in rd nee with 15 NC 2C 0 13. �
4b.CONTACT PERSON/VYELL OWNER: �[
NAME Deborah Hefner NDONING THE`.INE LL 4
STREET ADDRESS
97 Robin Lane, Taylorsville, NC "
l�
Submit a copy to h owner and'the orlginaj toc Diwisron of Water Quality'"int illon Processmy, Form GW-30
1617 Matl Seance Center,Raleigh,NC 769, Phone (919)80T-6300 "� I Rev.5110

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