New Hanover_Well Abandonment_20221031

WELL ABANDONMENT RE O D OCT 3 1 2022'
NoAh Carolina Department of Environment and Natural Resources-Division of Water Quality -
WELL CONTRACTOR CERTIFICATION# n;cfa s :l rsr aaT4(F3 Untl
r r
1.WELL CONTRACTOR: - 5. -WELL DETAILS: e
Ma.Total Depth:�.R D amder Z
Well Contrxtor(Individual N b.Water Level g )
S � ` ,v , 1 1 (Bcknv Measuring Point:,��A
�/ 1 1� l 4 1 Measuring point is 1L above Ind surface.
Well COnDICtDr Company Name
M
STREET ADDRESS a.V �- C CASING: Ieng16 Diameter
CokS-t 1� l�/� o 1" `C Al'C- a.Casing Depth(if known): 3_R. in.
City or Town Sddc Zip Code 6G b.Casing Removed: Ill. in.
�3l - _
Am code-Phone numb 7. DISINFECTION: a ++ 1 1b;
2.WELL INFORMATION: ��/�+, (Amount of 65Y.75%calcium hypochlorite used)
SITE WELL ID#(if applicablc) 7 & SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat C . , Sand e•ement
COUNTY WELL PERMIT It(if appbcsbk) Canent lb. Cement lb.
v Water gal. Water - gal.
DWQ or OTHER PERMIT#(if applicable) licitimite
WELL USE(Check applicableuse): ❑ Monitoring Po Residential Bentonite lb.
❑ Manicipal/PubOt ❑ IodastriaUCommercial ❑ Agricultural Type:[I shiny ®Pellets
❑ Recovery ❑ Injection ❑ Irrigation WmeT—to--g-L
El Other(list use) Other
Type material _
3.WELL LOC.ATI
COUNTY AHwinoyrfQU D ANOLE NAME Amount
NEAREST TOWN: a
9• EHLAIN 0;)r�rEMPL7CE'M/ENT OOF QTE IAL:
(Soee dRoa�•tadd Throne,Naniber,Covoanity,Subdi IviaiM 1a No.po=L Zip Cade)
_ e1rYY�
TOPOGRAPHIC/LAND SE'TTTNO: ..- s- �+
❑Slope ❑VaHey ❑Flat ❑Ridge❑Other
(Check appropriate setting)
1L WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
--]
Kd.i.l
e i,
LATITUDE _ _ fora showing total depth,depth and diameter of screens(if any)remaining
- - da.arms
LONGITUDE t in the well,gravel interval,intrnais of casing perforations,and depths and
types of fill materials used.
Latitude400gitudeseer": ❑GPS ❑Topographicmap 7- Z7-- ZZ
(Location of well must be she"on a USGS topo map and 11. DATE WELL ABANDONED
af1m1 ed Io this form if nat using GPS.)
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY,The mate of the business what the well in heated Ca ipkae 4a and4b. WITH ISA NCAC 2C,WELL CONSTRUCrPWANDARDS,AND THAT A COPY OF
(Ifa residential well.skip 4c complete 4b,well owner mfomntion only.) THIS RVCO§D HAS PRO DE EWELLOWNER,
FACILITY ID#(irapplicable)
NAME OF FACILITY I
STREET ADDRESS SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
City or Town stale Zip Cade SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(the Nivate well owner oast be an hmdivldrrafwho pyractullyabardoru hiaMer residential well
46.CONTACT P RSONi"LL 0 TER: m+a ee/lwti_W I_SA NCAC 2C A113.)
NAME V I F 11l SSLIP� �
STREET ADDRESS O S r PRINTED NAME OF PERSON ABANDONING THE WELL
lv� . C.
SabmR a copy to the owner and the original to the Dirktoo 4d Water Quality within 30 days. Fomr G W-30
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phoce Na.[phone] est 56R. Rev.5106

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3(/�f WELL ABANDONMENT RECORD 1 North Carolina Department of Environment and Natural Resources-Division of Water Quality OC i 3Z�ZZ.
WELL CONTRACTOR CERTIFICATION#
I. yy\(C NTRA CTOA: 5, -WELLDETAILS:
7 �M PA a.Toml Depth:_ft. Diamctor.
Well r�tnticlpr(1� w Name �• b.Water Level(Belem Measuring Point): �OZS R
Well
.C`mJ��-a�c.(to�r(�l1Campmy[,NJn\`ree1�1 �����I Measuring point is��fL above land surfax.
STREET AJIDRESS a f Tom "'�yt6. CASING: Lowit Diameter
a. " HQi/ f c- a.Casing Depth(if known):fL C in.
City or Town State Zip Code b.Casing Removed: _R in.
Area code-Phone number 7. DISINFECTION:
2.WELL INFORMATION: (Amount of 659'.75%calcium hypochlorite wed)
SITE WELL ID#(if applicable) 9. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) N tCment Sand Vewunt
COUNTY WELL PERMIT#(if applicabk Cement lb. Cement lb.) Water. gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) B Ite r
WELL USE(Checkapplicableuse): [I Monitoring esidrntial Benntonik '_7J lb.
❑MonielpaltPublic ❑ Industrial/Commereiai ❑ Agricultural Type:El Slurry gVeillets
❑ Reeove ❑ Injection • Water 15
!�.
[] Recovery ) ❑ Irrigation
❑Other(list me) Other'
Type material
3.WELL LOCATION- Ammmt _
COUNTYNec�rN' QvUADRANGL/E! fE
NEAREST TOWN. 1 9. BJCP N METHOD OF EMPLACEMENT OF hS�
ATE AL:
3u�f b �l�o mia `6 s , y Ov
(StmedRaul Naas,Number,Cmmoiy.Subdivision,W No.,Parcel.Zip Code) Ty n-t_ Q .
TOPOGRAPHIC/LAND SETTING:Vgz� OVallcyy ❑F7at ❑Ridge❑Other
(Check appropriate setting)
10. WELL.DIAGRAM:Draw a retailed sketch of the well on the back of this
May be in degree.. farm showing g total depth,dap.hand diameter of screens(if any)remaining
minimal, or in a ormig s, in the well,gravel interval,intervals of casing LONGITUDE decimal format gm g perforations,and depths and
types of fill materials med.
Latitude/longitudesouree: ❑GPS ❑Topegraphiemap - _a G _ \�
(Location of well must be shown on a USGS tope map and 11. DATE WELL ABANDONED C,
attached to this farm if not using CPS)
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDON IN ACCORDANCE
4a.FACILITY.The tome of the busiuurss where the well is kcataLL Complete 4a nnd4b. WITH ISANCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COP'OF
(Ifa midential well,skip 4a;complete 4b,well comer infomotim only.) THIS REC RD HAS BEEN PROVIDER WELL OWNER I
FACILITY ID#(dapplicabic)
NAME OF FACILITY
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS
City or Town Store Tip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(Deprivae wallownrmetbc an vAvxk%fwho mrsonallyabandom hiatherrosidernial well
4b.CONTAC(�T,PEE�R�S(O`NIWEELL OW�N/$�R(�5��(/ m writth,I,SA NC1AC 2C.011 .)
NAME)ll QiCk 1 " e c CT�L�,�4 J Sc_
PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS�n -
a
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW 10
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699.1617, Pboue No.[phone] ed 560. Rev.5/06

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