Rockingham_Well Abandonment_20230104

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WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources Division of Water Quality
WELL CONTRACTOR CE1tTIFICATION#f
I.WELL CONTRACTOR: rL WELL DETAIIS:
a Total Dep1b: fU Diameter-�` in.
Well C//ontrrsoor/(Individual)Name b.Water Level(Below Measuring!Point) J tt
✓DLtn �1�,'�f/J Siri,�li �.t�G/� t'0. IhG- Alm-ingpoinfis fLabovelandsurface_
Well CbrtftactorComphity Name -
STREEPADDRESS r>?-- 6 3 &1&,k 6. CASING- Length Diameter
//1 Q V A 14C j 7,0.27 a.Casing Depth(if)mown): R ��k in.
City Ir Town State Zip Code b.CasingRemoveEL �' `in.
( 331
Area code-Phone number 7- DISINFECTION: /j L &
2.WELL DNIFORMATION: (Amount of 65%75ala calcium hypochlorite used)
SITE WELL II)#(if applicable) 8. SEALING MATERIAL:
STATE WELLPERiVIIT#(if appE able) Neat Cement Sand('ement
COUNTY WELL PERMIT#(ifappbcable)_ �"/�G,�P Z /� �/L Cement—lb. Cement lb.
Water gal- Water 90L
DWQ or OTHERPERMIT#(ifapplicable) Bentonite
L6 �r .
WEL (Check.applicable USE t
applicable use): ❑Monitoring Residential Bentonito !b. �'�4'"t""c " ° fin~ X`�"r`
Municipal/Pubiic 0-Industrial/Commercial ❑Agricultural Type:❑Slurry OPeilets JAN � 4 2023
❑Recovery ❑Injection ❑Irrigation Water Sal_.
Other
lftivi:d��-• •:7
Other(list use)
Type material c G M Z w (/t D N u ck
3.WELL LOCATION: Amount -S
COUNTY fae`f.tA 6, }bADRANGLE NAME
NEARESTTOWN: S w>n m e v ��1 l I
r 9. EXPLAIN METHOD OF F�"rLACEAIIIVT OF MA
7 Cl�6 IIJ� 1., 73 5 7 o CZ (��7't7 r
(StaxtlRoad Name.Number.Comae city.Subdivision.Lot No..Parcel,Zip Code) [-� ! yt
TOPOGRAPHIC/LAND SETTING:
[]Slope []Valley OFlat ❑Ridge❑Other
(Check appropriate setting)
0 10. WELL DIAGRAM:Draw a detailed sketch of thewell on the back of this
LATITUDE �j , 9 L Z. Maybe in degees, fomt showing total depth,depth and diameter of scteeos(ifany)remaining
minutes,seconds.or in it
LONGTTUDE ,�, (' dcchnal fog - in the well,gravel interval,intervals ofcas ng perforations,and depths and
types of fill materials used.
Latitudeflongitudeson= W&S ❑Topographictnap
(Location of well must be shouw.on a USGS topo map and 11.'DATE WELL ABANDONED' Z 2—
attached to thisform ifnot using GPS) '
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
42.FACILITY The nay of the business where the well is hrcated Complete 4a aad46 WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT A COPY OF
(Ifa residential will,slip 4a;camptete 4b,well ownerinformation only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY D)#(if applicable) 6y — 1,-2 1
NAME OF FACH=
STREET ADDRESS
SIGNAIVRE OF CPTIFIED WELL CONTRACTOR DATE
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The prorate well ownerrmat be,an iadividual who versonallvabandons hs/herresideatial wen
4b.CONTACT PERSON/WELLOWNER- in atxorda-nce with 15ANCAC-2C.0113.)1
NAME 9.+_M rY l a,fr O t/�. C- r` /i S r v 4
STREET ADDRESS. 0, 3 g - PRINTED NAME OlftERSON ABANDONING THE WELL
i
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. I Form GW 30
Attn:Information Management,1617 Mail Service Center' Raleigb,NC 27699-1617. Phone No.(919)733-70I5 ext 568. Rev.5106
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