Pender_Well Abandonment_20221031

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WELL "ANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality r 3 ) 2022 .
WELL CONTRACTOR CERTIFICATT_ON#
1.WELL CONTRACTOR: 0. 'WELL DETAILS:
a.Told Depth: 97 ft. Diameter:_ in.
Well Ctotrntxor(tadividuat)Name n
sagL. �ytt1� 'p(i(Ilny � rIIMP $N✓'�C,S b.Water level(Below Measuring pointli ring Poini):�_R.
Welk Compmy^Nm1oe * Measuring point is-Ir y_ .above land surface.
STREET ADDRESS }O`I I 0 tit A✓ a✓L 6. CASING:
Length Diameter
CA014L N„11I1 plc 2YNaq
a Casing Depth(if known): lZa—fL �in.
?
City 2 To. 691FSanta Zip Code b.Casing Removed: fL in.
q( 10 )_ 31 ' 44
Am code-Phone number - 7. DISINFECTION: Ib
L WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
SITE WELL ID#(if applicable) S. SEALING MATERIAL:
STATE WELL PERMIT 0(if applimblc) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable) Cement Ib. Cement 16.
.. Water goL Water gal.
OWQ or OTHER PERMIT 4(if applicabk:) itil _
WELL USE(Check applicable use): ❑ Monitoring KReddeatLl Bentonite 50 lb.
❑ Men)cipaFPubhe ❑ Industrial/Commercial ❑AXrkWW l Type:[I Slurry A Qlfellets
11 t�rIRecoveryRevery ❑ Injection Irrigation Wmer_4AD_ _gal.
❑Other(list use) Other
Type material
3.WELL LOCATION:
COUNTY LAAr Amount
QQUADRANGLE
NFARFSTTOWN: �m1 Let ,IG �fHr14
22-2 510op 1'O_nf Lot (t NAPIfs fdr 9. EXPI.MN METHO`F EMPLACEMENTPat- OF MA AL;O
(Sa mn-vRoad Name.Number.Conity,Subdivisim,[a No..Patois,Zip Coda) �+ •l — uy lowley A- is T�—
TOPOGRAPHIC/LAND SETTING: tga r- [_ICI cr t e�—
❑Slope ❑valley Flat ❑Ridge❑Othcr_T_
(Check appropriate setting)
10. WELL,DIAGRAM:Draw a detailed sketch of the well on the back of this
Ld-N.atuses,
ay be indcgmo,
r LATITUDE —— soconds,or in a fom showing total depth,depth and diameter of seteens(if any)remainingecimal fsmt in the well,gravel interval,intervals of casing perforations,and depths midLANGTTUDE
types of fill materials used.
Latitudelbagitudesetace: ❑CPS ❑Topogtaphicmap
(Location ojwell must be shown on a USGS ropo map and ]L DATE WELL ABANDONED
attached to this form if not using GFS)
1 DO HEREBY CERTIFY THAT INS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY;The name of the ineimss when the well is located.Cea late 4a an44b. W i H 15A NCAC 7,C,WELL CONSIRIICTION STANDARDS,AND THAT A COPY OF
(Ifa midential well,skip 4a;complete 4b,well owner inlen ation only.) THIS RECORD HAS BEEN PROVIDED TO. E WELL OWNER
FACILITY ID#(i(applicable)
NAME OF FACILITY _ (D t3- o7 a
SICNA REO
STREET ADDRESS IED WELL CONTRACTOR DATE
City"Town Sinc Zip Code SiGNATUREOFPRIVATEWEI"LOWNERABANDONINGTHEWELL DATE
111 a Rivet well Owner nano be an mdividpdwho loatilla((yabaadaes haybvspidedial well
4b.CONTACT PERS TLL_"E ����� n 15A NCAC 2C. 113.)
NAME ((J� FO ,/t I c l,ael C Sage. -
STREEf ADDRESS le `� Sloop Omer/ Lai ► ) P NAME OP PERSON ARANDOMNG THE WELL
pit � y 7 L
Submit a copy to the owner and the original to the Division of Water Qua01y within 30 days. Font OW 30
Attn:Indbroutlon Managemen41617 Mail Service Center-Raleigh,NC 2709-1617, Phom No.(91n 7317014 ert 56E. Rov.5106