Sampson_Well Abandonment_20221028

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WELL s( ialt�' s WELL ABANDONMENT RECORD
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North Carolina Department of Environment and Natural Resources-Division of Water Quality i WELL CONTRACTOR CERTIFICATION# PP
1.WELL CONTRACTOR: 5. WELL DETAILS:
fl1 d 4W.0-104(x
�`t��l�I /►�/K a.Total Depth: �ft. Diameter: / in,
WCII ontractor(individual]�Name
�` b.Water Level(Below Measuring Point):' ft.
/n�,die �-j�.O/�r� e� � f:��w t Measuring point is fl.above land surface.
vN-rclI Contractor Company/vNfamee
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6. CASING: Length DiameterD AW1�e1?d
r AD
'PRESS cfgoFla
IF_ _ a.Casing Depth(if known): fl. /y in.
W—d or Statc_O Zip Codc b.Casing Removed: _ft. �_i
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Area code-Phone number 6OI(J 7. DISINFECTION: /(�✓�
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
-_ SATE WELL ID#(ifapplicablc) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
�/ Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable)' II/0�~ Water gal. Water gal.
DWQ or OTHER PERMIT i#(if applicable) Bentonite
WELL USE(Circle applicable use): Monitoring Residential Al r f�
Municipal/Pubiic Industrial/Commercial Agricultural Bentonite V lb. I
Recovery Injection Irrigation Type:Slurry_Pellets_
Other(list use)
Water gal.
Other
3.WELL LO TIyO�N�:
UADRANGLE NAME Type material
COUNTY� ?V _
NEAREST TOWN: CtG_� � � Amount
(Street/Road Name,Number.Community,Subdivision.Lot No.,Parcel,Zip Code) 9. EXPWN METHOD OF EMPLACEMENT OF MA ERIAL:/1 0
T PH IC/LAND SETTING:
Slope Valley Flat Ridge Other ct /1& -
(Circle appropriate setting) ,] t
LATITUDE s OW May be in degrees, _
minutes,seconds.or in a
LONGITUDE �_�� decimal format 10. WELL DIAGRAM:Draw adetailed sketch of the Weil on the back of this
- - - --L-atitude/fottgitude source: -GPS---TopUgraphic trap - -- fo rtLt shoxr_ing total_depth.depth and diameter of screens if any)remainin
(Location of well must be shown on a USGS topo niap and in the well,gravel interval,intervals of casing perforations,and depths and
attached to this form if not using GPS.) types of fill materials used.
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b.
(ifa residential well,skip 4a:complete 4b,well owner information only.) 11. DATE WELL ABANDONED ((//
FACILITY ID##(if applicable)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY WITH 15A NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED HE WELL OWNER.
STREET ADDRESS_
City or Town State Zip Code SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
4b.CONTACT RS EL OWNER:
NAME �A��� SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
yro (The private well owner must bean individual who personalI abandons histher residential well
STREET ADDRESS C in ac ord tflc with 15A C 2C..0113.)�
It
City or Town State Zip Code PRINTED NAME OF P SON ABANDONING THE WELL
Area code-Phone number
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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