Iredell_Well Abandonment_20221114

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WELL ALRANiDONMENT RECORD
North Carolina Department of Bavironment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# (,/ � !�
1.WELL C NTRACTOR. 5. WELL DETAILS: mi�ll--^^
���,_ a.Total Depth_ ft. Diameter/sin.
wen Co c(or(individual)Name b.Water Level(Below Measuring Point): _fl`
es Measuring point is t ft.above land surface.
Well ordractor Company Name
3' S ✓il 6. CASING: Length Diameter
Str t Address ..>
a.Casing Depth(if known): in.
2r Town State Zip Code b.Casing Removed: ft. in.
Area
code Ph on��r '� 7. DISINFECTION:
2.WELL INFORMATION (Amount of 650/675%calcium hypochWte used)
SITE WELL iD# (if applicable) $• SEALING MATERIAL:
NaatCamant $andCamant
STATE WELL PERMIT# (if applicable) iOSu
Cement lb. Cement lb.
Z Z a z
COUNTY WELL PERMIT #(ifappticable) Water gal. Water Ial.
_�
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Cheek applicable use)D Monitoring lYResidlalont Bentonite ib.
Type;J Slurry R Pellets
U MunicipaUPublie G Industrial/Commerclat 0 Agricultural Water gal. �•��E E � ED
� �
D Recovery U Injection i= Irrigation Other 5
Ci Other(list use) Type material N O y 2G22
In'.0m bisn'rxD c ,'g Urx
3.WELL LOCATION: Amount
COUNTY.L� QUADRANGLE NAME
NEAREST TOWN: 9. EXPLAIN METHOD OF EMP CEMENT OF MATERIAL:
(StreelfRoad Name,Number,Community.Subdivision,Lot No.,Parcel.Zip Code)
e
TOPOGRAPHC/LAND S/ETIING:
Il Slope $-I Valley lat r l Ridge`_]Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
?�j�p� �/���.— • ' form showing total depth;depth and diameter of screens(if any)remaining
LATITUDE 3S,L�� r�,. aDMS OR 3X.XXX)ow-yadD in the well,gravel Interval,intervals of casing perforations,and depths and
LONGITUDE X—6-°�' It g DMS OR 7X-XXXXXX10 VD types of fill materialarsed
LaGtudenongitude source: [%fS Oropographlomap 11. DATE WELL ABANDONED
(location of well must be shown on a USGS topo map andaHached to
this fomr if not using GPM 1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH CORD
2C.WELL CONSTRUCTION STANDARDS,AND THAT COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a. ECORD HAS BEEN P9%ADED HE 0
(If a residential well,skip 4a;complete 4b,well owner infommtlon only.)
FACILITY ID#(if applicable) _ v/z__
NAME OF FACILITY Si RE OF CERTtFiED RACTOR ATE Y
STREETADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private welt owner must bean ind'nrkival w�i n9ap bandons hisfier residential wel!
in a ce with 15A NCAC 2C.0113.
4b.CONTACT PERSONIWELL OWNER: p � � �41,4,1 T'
NAMES �' 3 ; PRINTED kAME OF PERSON A©ANDONING THE WELL
STREETADDRESS &Qj 7ULiVI 11lW— Pe,-> s
'Submit a copy.to*i9 oinrner and the original to Dlvision.of Water Quality-Information Processing, Form GW-30
1B17 Mail Service Center,Raleigh;NC 27689=1817,Phone [phone] Rev.5110