Rowan_Well Abandonment_20221114

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' WELL ABANDONMENT RECORD
• S;, North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 6. WELL DETAILS,
g Pt� a.Total Depth It. Diameter. Z in.
W II Contractor(individual)Name b.Water Level(Below Measuring Point):fL
p LO U-n W"I Dr> >>► Measuring point is r ft.above land surface..
Well Contractor Company Name
Sh er r i l 1 s Fo v-cL 6. CASING: Length .Diameter
Street Address !�hlG�r .
CLI i Sb LlY N R t_ o1S l a.Casing Depth(if known): 'ft. in.
City or Town State Zip Code b.Casing Removed: _ _fL in:
(�0 41 Q 7. DISINFECTION: LL3 z
Area code Phone number
(Amountof 65%75°/a calcium hypochiorite used)
2.WELL INFORMATION:
: 8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
NeatCemant Sand Cement
STATE WELL PERMIT# (ifapplicabre)
�7 Cement.lb. Cement lb.
COUNTY WELL'PERMIT #(if applicable) / J water gat. Water oai.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite Ib, 1 6�C
WELL USE(Check applicable use)D Monitoring Residential �� 4 t,
Type:❑Slurryeliets f s
❑ Municipal/Public ❑ IndustriallCommercial ❑ Agricultural Water In gal. NOV 1 2022
Cl Recovery ❑ Injection ❑ Irrigation Other
In;k?rs7l�ti;;;I i'rx ,s,^,�Ursa
❑Other(list use) Type materials
Amount
3.WELL LOCATION:
COUNTY�a ' QUADRANGIE NAME
NEAREST TOWN: Chi no- 6y-f)11 9. EXPLAIN METHOD MP�IACEMENT OF MATERIAL:
(Skeet/Road Name.Number,Community,Subdivision;LotNo.,Parcel,Zip Code)
TOPOGRAPHIC I LANDS NG: W ��
i
i_l Slope ❑Valley KFIat ❑Ridge❑Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw.a detailed sketch of th II an the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE /'_ �/07 " S OR 3X.XXXMOOOWD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE_-_&' q.6 "DMS OR7X.XM=X)=D types of fillmaterialsised
Latitudenongitude source: QGPS Q /ropographic map 11. DATE WELL ABANDONED / d/ /z
(location of well must be shown on a USGS topo map andaffached to
this form if not using GPS) : I DO HEREBY CERTIFY THATTHIs 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 4e t THIS ORD HAS BEEN POVIDED T 'rHE L O
(If a residential well,skip 4s,complete 4b,well owner information only.) Q Z 11 Z
FACILITY ID#(if applicable)
NAME OF FACILITY N URE OF CERTIFIED LL ONTRACTOR OA E
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONINGTHE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wh2tMn—a-lbabandons hisAwresidential well
in accordancewith 15A NCAC 2C.0113.)
4b.CONTACT PE�IRSONIWELLOWNER: `�acRf it�kG e'K 40/4 '&'7
NAME i/Lq&( V g Z� a;Z PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS Z /n/
'frog Chrot�L. nc'
Submit a copy., theowner:and the original to.Division,of Water Quality.-Information Pr©ceasing, Form GW-30
I617 Mail Service.Center,Raleigh;NC 27699 1B17,Phones(919).807 6,300
Rev.5/10