Iredell_Well Abandonment_20230109

ARA11T1�ONMENT RECORD
NortkCarolina Department ofEnvifotunent and Natural Resources-Division of Water Quality
... WELL CONTRACTOR CERTIFICATION# q
1.WELL CONTRACTOR: C V ` ba WELL DETAILS:
D n» (La nn►w a.Total Oepth- toy_ it. Diameter--z
Welt Contractor(individual)Name I �23 ; b.Water Level(Below Measuring Point):-!�—IK—tL
Measuring point Is ft•above land surface. -
Weil Contractor Company Name
►�.g LE.a 5hQ r r i)t s r0 r cl c� D f° s. CASING: Length Diameter
Street Address
�r � �i�h a,Casing Depth(if known):
C
c� &0. ,bLL H ~ b.Casing Removed: 140 ft. in.
City'or.Town State Zip Code
r1( b 4 l �+3(O g �t : 7, DISINFECTION: C 1bY _
Areacode_Plmnenumbiar
(Amount of850/675%calcium hypochtoAte used)
2.WELL INFORMATION: g, SEALING MATERIAL:
SiTE WELL ID# (if applicable)
NoatCement gandCament
STATE WELL PERMIT# (if applicable) Cement ifi. Gement Ib.
Water —gat. Wajgr oaL
COUNTY WELL PERMIT #(if applicable)- ftntani
DWQ or OTHER PERMIT#(if applicable)
�y Bentonite lb.
WELL USE(Check applicable use} Monitoring > Restdentlal Type:J Slurry _. eilets
t7. M unicipaUPubiie 0 IndustriallCommercial a Agricultural Wate 'gat,
CI Recovery El. Injection Ci irrigation Other
i7 Other(list use) Type material
Amount
3.WELL LOCATION:
COUNTY lr9le-1 i QUADRANG1ENAME -
NEAREST TOWN: 0 D f 2 S Yr Ile, 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
A4 to Vol � f or
(Street/Road Name.Number,Comtxmity.Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC i LAND SETTING: �� G
1-1 Slope 0 Valley 0 Flat Ci Ridge`D Other
(Cheek appropriate setting) : 10. WELL DIAGRAM :Dra%S a;detailed sketch of tiriall on the back of this
form showing total depU,depth and diameter of screens Qf any)remaining
LATITUDE � DMS Olt 3X.XIOciocX 0M0 (ri the well,gravel interval,Intervals of casing perforations,and depths and
LONGiTU.DE ��'� OR7X.XXlWOOUL14D typesoffillmatertalsiseci
_ I
LatitudellangitusoUrce: QGP$ Qropographlc map 11. DATE WELL ABANDONED
(location of well must be shown on a USGS topo map andefteched to
this form if not using GPS) : 100 HEREBY CERTIFY THATTHIS WELL WAS ABANDONED IN ACCORDANCE
: WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THATA.COPY OF
4a.FACILITY-The name orthe business where the welt is totaled.Complete 4a : THIS RECORD BEEN peviDED TOTE WELL OUINER. J
(il a resdenMt wets,sktp 4a;eomplete4b,welt owner Information wdy.)
FACILITY ID#(it applicable)
NAME OF FACILITY SIGATUREOF CER I CONTRA TOR O E
STREET ADDRESS y !
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The privatewellownermmst bean indWua)vrbersOMMobandomhMwfestdenUBlwell
City or Town State Zip Code
In accordance . 15A NCAC 2C.01 .)
4b.CONTACT PERSONIWELL OWNER: . in P n 1
NAMEaL+fA- tv z Sikctuark- -► DL��-�T P PRINTED AMEOFPERSO `BA NINGTHEWELL
STREETADDRESS
Submit a copy to the.owner and the original to Division of Water Quality-ltiformatlion Processing, Form GW-30
1617 Mail Service Center,Raleigh;NC 2*6694617,Phone•.(919)807 poo
j Rev.5f10
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1 � WELL ARADMIMiyT RE-M.
North Carolina Department of Environment.and Natural Resources-Division of Water Quality
" .; WELL CONTRACTOR CERTIFICATION# i/
1.WELL CONTRACTOR: 5. WELL DETAILS: J,
a. ''•• n to I >`. ,r .P.n t ® a.Total Depth S tt Diameter. in.
1 ,�, <, `
Well Contractor(Individual)Name b.Water Level(Betovs Measuring Point):_Jim ft
7023 Measuring point is_ +`� ft.above land surface,..
Well Contractor Company Name
or o
4$1.p 6V)Cyri!!S Ft"r c � F�_.-: ��?r:: yr 3 6t CASING; Length Diameter
Street Address 5-V.Uj`U- ,
SL�.I f SbU v'�j r1C„ wa i O a.Casing Depth(ifknown): 14 R. 2l in.
City or Town State Zip Code b.'Casing Removed: 4�___ft. �in.
7, DISINFECTION:
Area code Phone number
(Amountof(I5%75%a calcium hypochlorite used)
2.WELL INFORMATION: S. SEALING MATERIAL:
SITE-WgLL ID# (if applicable)
NaatCamant qand camaot
STATE WELL PERMIT# (if applicable)
Cement ip. Cement lb.
COUNTY WELL.PERMIT #(if applicable) D Z 2 g Water gal Water eat.
Belltonite
OW4 or OTHER PERMIT#(if applicable)
Bentonite Ilb
WELL USE(Check applicable use)] Monitoring JR Residentlel T Swm, a/ts
ype: 1�l
❑ MunicipaliPubtle 0, Industrial/Commercial 0 Agricultural Water it gat.
Cl Recovery t Injection C Irrigation Other
0 Other(fist use) Type material
Amount
3.WELL LOCATION:
COUNTY 1 t I A t 1 i_QUADRANGLE NAME
NEAREST TOWN: D b Y!5 v I t c. S. EXPLAIN METRO OF EM LACEMENT OF MA RiAL:
(Streel/Road Name,Number,CammunItY,Subdivision.Let NO--Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
iJ Slope 0 Valley 0 Flat 1.1 RidgeD Other
(Check a propriate selling) 10. WELL DIAGRAM:Draw a detailed sketch of theell on the bade of this
_ trl farm showing total depth,depth and diameter of screens(if any)remaining
LATITUDE .. _ , ,J.� � 11���� OR 3x.XXXX)ocXXIOD In Ne well,gravel Interval,Intervals of casing periorattons,and depths and
LONGITUDE��l-'—.2-L-PPMS OR 7X.XXXXXX=D fYPe5 of fin materialaaed
LatitudelfanEijeosource: SOPS pfopographlc map 11. DATE WELL ADAN66NED
(location of well must be shown on a USGS top*map andattached to
this form if not using GPS) i DO HEREBY CERTIFYTHAT THIS WE1-1.WAS ABANDONED IN ACCORDANCE.
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY.The name of the buslnese where the wall.is located.Complete 499 THIS RECORD S BEEN PRVIDED TO THE WELL OWNER.
(Ile residential well,skip 49;complete 4b,wag owner Wormation only,) 7
FACILITY ID#(if applicable) L
NAME OF FAC W,QyATUREGF iF1ED WELL ONTRACTOR TE
I.
STREETADDRESS y
SIONATUREOFPRIVATEWELL OWNER ABANDONINGTHEWELL DATE
City or Town State Zip Code : (The private wagownermustbeinindividualwheroonalhabandon.+h►s W residential wag
: in accattten with 15A NCAG .0113.)
4b.CONTACT PERSONANELL OWNER i h
NAME 4�-A aC.YcL 1'5 5f+t.wtYk{ Q.VQ,ia P PRINTED NAMEOFP ONAR DONINGTH WELL
STREETADDRESS PO pax St-74 i µsDrQ.ss'it�
aglv-i.
Submit a Copy.to the:Owner anti the original tp;Division:of Water Quality=lrtformation Processing, Form 110
1617 Mail Service Center,Rale h,NC V6»g-1B17.Phone:[phone] Rev.5Jf0
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ARIADMOMM
North Carolina Department of Environment and Natural.Resources-Division of WI titer Quality
WELL CONTRACTOR CERTIFICATION# 4L-i
1.WELL CONTRACTOR: _z,` 6. WELL DETAILS:
,� , -� ,.�
11Lh n • ' ' �l ,`� ,i* 1 a.Total De th R Diameter. ln•
Jahnn4 a � ,. aJrL i l.:.r i=
Well Contractor pndividuai)Name b.Water Level(Below Measuring Point): 0 ft.
•-R D 1Q L 1 J A N ® 9 20 23 Measurin
w 1{ Dr i t t i g point is A. ft.strove land surface
Wei)Contractor company Name►�8 et D. ntI" ` ."`n ?r':.
8. Diameterskorr;lls
Street Address ft.
�1Iisl 'rq hC olg l41 a CastngDepth(ifknowny;
b.Casing Removed: _�16 ft, In.
City orTown State Zip Code �,/
'(0 �3 T.1n I at . DISINFECTION: t �ax• Yt f
Area code-Phone number
(Amountof 65%75%catdum hypochlodte used)
2.WELL INFORMATION: 8, SEALING MATERIAL:
SITE WELL ID# (if applicable)
d@ntea►ria t Sand Cement
STATE WELL PERMIT# (ifapp►lcable) Cement lb Cement lb.
.9 0$2 $S�i 3 Water gat. Water aai.
COUNTY WELL PERMIT #(if applicable)
OWQ.or OTHER PERMIT #(if applicable)
Hentonite Ib.
WELL USE(Check applicable us8P Monitoring "01Restdential Type:ae„rry 0 Pellets
0 MunicipallPublic 01 IndustriallCommOrclal 0 Agricultural Water gal.
ii Recovery D Injection C1 Irrigation Other
0 Other(list use) Type material
Amount
3.WELL LOCATION:
COUNTY I FI A-Ll1 QUADRANGLE NAME
NF.ARESTTOWN: VIlL 0 OY"`►w 1 z 9. EXPLAIN METHOD OF EMPLACEMENT F MATERIAL:
P �- '-]•-r o u_. n-r1 taw. c ' �*� o
a�4 1,t�inr��aF 5 r
(StreetlRosd Name,Number,Community,Subdivtslon,Lot No.,Parcel,Zip Code)
TOPOGRAPHID I LAND SETTING:
0 Slope 0 Valley E3 Flat n Ridged Other
(Check appropriate setting) to. WELL DIAGRAM:Draw a detailed sketch of theetl on the back of this
?� form showing total depth;depth and diameter of screens(if any)remaining
LATITUDE_ J.y�. OR 3 D in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE__ OR7X.7C0WJ00MD types of fill materialsued;.
LatitudellongitVso ),F-.Zz
utce: 03PS orapogra/hle map 1i. DATE WELL ABANDONED
(location of well must be shown Orr a USGS top*map andattacbed to
this form If not using GPS) : 100 HEREBY CERTIFYTHATTHiS VVELL WAS ABANDONED IN ACCORDANCE
: WITH 15A NCAC 2C,VYELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY.The name of the business where the Wetl Is located.Complete 4e. : THIS RECORD HAS BEEN PIP DED TO THE WELL OWNER.
(if a midentiai well,sIdp 4o;complete 4b,well owner Wormelion only.) r , _
FACILITY iO#(if applicable) __Z 2-
ATU EOF I WELL C CTOR DATE'
NAME OF FACILITY
i
STREETADDRESS
X. : SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be 6IrdWual whersonathabandons hWw restdential well
In aceordencewifh.15A NCAC 2d.0113.)
4b.CONTACT PERSONiWELLOWNER. LYL 1L tA k1, ,
NAME �—A ti'�Cr 4-V+LV S S l6 i0�rkd� PRINTED NAME OF SON ABANDONING WE LL
STREETADDRESS �D 13aX 5iy�1 !U I)Orasvil��
a811'1 ii.
Sub►nit a copy.to the OW111OV,and the.original to:DlVlslon.of Water duality=Info. on Processing, Form GW-30
Rev.5110
1617 Mail Serviee,.Center,itatei'hP NC 176604617,Phone (910).dQ7 P..3oo
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�;� ' ;t y�i.r.Ai_hA�N�UNIViF.NT CORD
North Carolina Department of Environment and NaturdResources-Division of WaterQuality
WELL CONTRACTOR CERTIFICATION# L C
1.WELL CONTRACTOR: ��^ ;�, �„ WELL DETAILS: .
�^•� - _` ��'? a.Total Depth h Diameter In.
Well Contractor QnefivIduaQ Name J A b.Water Level(Below Measuring.Point): % R
—.-�'h ` )e ,1 , ® 9 2 23` Measuring point is��ft.above land surface.-
W1`ei)ContractorCompanyName , i � roc, •Ri Un'f
`CS L{o t�`l RY r I j 5 FD I d 6�e t�i::; 3k� 6." CASING: Length Diameter
Street Address
a.Casing Depth(if known):. —�-ft. in.
S Q j j Sb I,r_Y h 0 C a 81 .
City of Town
State Zip Code b.Casing Removed: in.
ft
{ '7 D'F) (O3(0 7 g? 7. DISINFECTION:
Area code Phone number
(Amountof65°Jo7595 calcium hypochlorite used)
2.WELL INFORMATION:
t & SEALING MATERIAL:
SITE WELL ID# (if applicable)
HeratSement Sand Cement
STATE WELL PERMIT# (if applicable)_: Cement iti. Cement _-lb.
COUNTY WELL PERMIT #(if applicable) ZD 2 S Water gat. Water oal.
Bentonite
DWQ or OTHER PERMIT#(if applicable)
Bentonite IIb.
WELL USE(Check applicable useP Monitoring residential Type luny O Pellet's
L M unicipallPublic 0 IndustriallCommerciai .0 Agricultural Water `/OD 'gal.
i
CI Recovery C Injection G Irrigation Other
0 Other(list use) Type material
- Amount
3.WELL LOCATION:
COUNTY t"L�zt I QUADRANGLE NAME
NEAREST TOWN: DU r tell t)i e, 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
� Gvtsss�ra+1 R�-
(StreetiRoad Name,Number.Community,Subdivision.Lot No..Parcel,ZiP Code)
TOPOGRAPHC I LAND SETTING:
I
0 Slope n Valley n Flat l Ridge`l Other
(Check appropriate setting) 10, WELL DIAGRAM:Draw a(detailed sketch of theellon the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 36 J:g2j,5, _DMS GR 3X.XX70 OO=D [A the well,gravel interval;intervals ofeasing perforations,and depths and
LONGITUDE 75-"—,5 4°DMs OR 7X.XXXXX)=D types Of fit'matetfalmsed'
IzIgI2z'
Lal itudellongitude source: MPS Ciropographlo map 1f. OATE WELL ABANDONED
(location of well must be shown on a USGS topo map andettached to
this form finot using GPS) : I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED iN ACCORDANCE
WITH 15A NCA02C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4e.FACILITY.The name ofthe business where the well is located.Complete 4e r THIS RECORD BEEN DED TO T E WELL OWNER.
(if a residential well,ekip 4s;complete 4b,weft owner khrmation only) r < 12.
� 22
FACILITY ID#(f applicable)
NAME OF FAGlI tTY t URE OF C TIFI W RACTO DATE
I
STREETADDRESS
: SIGNATURE.OF PRIVATE WELL OWNERABAN INGTHEWELL DATE
CitycrTown State Zip Code (The private welfownermustbeahhidividualwpliggag%abendonshisAterresidenUalwell
in accordance with 15A NCAC 26:0113.)
rib.CONTACT PERSONNVELL OWNER: J fib r,r Ui �L`Lj'
NAME a LrQkters �'i 1A)D r IL• { i�Lt1 8 P PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS Pb 6D ' 15124
as117 � ,
Submit a cgpy to the._own rand rho.origipal to:Division:of Water Quality-irtfom>tatlon Processing, Form GW-30
-1617 Mail Service Center,Ralisto,NG 27699-161T,'Phone:[phone] Rev:5110
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�,f,'. � WELL�A._NUONMENT CORD �
4' Isrorth Carolina Department of Environment and hahuaLResotuces-Division of Water Quality
WELL CONTRACTOR-CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS:
a.Total Depth ft_ Diameter.=� In.
9
Well C tractor(indivi ai Name b.Water Level(Below Measuring Point): fL
`_ `�,9! Measuring point is `ft•above land surface.Well Contractor Company N e
�` s • / 6. CASING: i Length Diameter
Street ddre5s a.Casing Depth(if known) ft,Uzl
State Zi Code b.Casing Removed: ; ft. in.
City or T n p
7. DISINFECTION- 2'
Are( 7 a code) .Phbne number
(Amount of 650/67574 calcium hypochtorite used)
2.WELL INFORMATION: 8. SEALING MATERIAL:
SITE WELL 10#(it applicable) NaatCarna t gand Cement
STATE WELL PERMIT# (if opp.licabfe) Dement Ib. Cement lb.
Water gat. Walq Dal.
COUNTY WELL PERMIT #(if applicable) �� � r
Bentanite
DWAorOTHERPERMIT#(ifappticable)
Bentornte ce, Ib.l may,�;='A R7 F'.
WELL USE(Check applicable used Monitoring VResidentlal Type:`' Slurry D Pellets
0 MunicipaUPublie (~ Industrial/Commercial D Agricultural Water—�� gal. JAlv 0 92023
0 Recovery C: Injection Ci Irrigation P!!3s a
lrlS`tiF�:��•; it�t�^-•^y^ lP.��,� !
Type
D Other(list Typ
.use)
Amount
3.WELL LOCATION:
COUNTY_�:i&i/QUADRANGIE NAME
✓ 'r
S. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
NEARESTTOWN:
(Street/Road Name.Number,Con jundy.Subdivision,Lot No..Parcel,Zip Code) r aL'piIT,
u
TOPOGRAPHC/LAND SETTING:
i
1-3 Slope n Valley 0 Flat 0 RidgeD Other
(Check appropriate setting) 10. WELL DIAGRAM ;Draw l detailed sketch of thee{l on the back of this
form showing total deplb.,depth and diameter of screens(if any)remaining
LATITUDE .3 -5'; -- "DMS OR 3X D i6 the well,gravel interval,Intervals of casing perforations,and depths and
{� „ types of fill materiaimsed
LONGITUDE75t�`�-{�-�— DMS OR7X.X)OCX)O=XD
Latitudenongitude source: QGPS Qiopograph{c map 11. DATE WELL ABANDONED
poaadon ofwell must be shown on a USGS topo map andadached to
this form-Nnot 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 ofthe business where the wed is located.Complete 4a: THIS RECORD S BEEN PRVIOED TO THE WELL OWNER.
(if a residential wall,skip 40;cowl%e 4b,woo owner informatlon onty.) �, ?
FACILITY ID#(if applicable) GATE
SIG A R I 1 .WELLCONTRACTOR
NAME OF FACILITY
STREET ADDRESS LI.OWNERABANDDNiNGTNEWELL
_ SIGNATURE OF PRIVATE WE DATE
(The private wei(ownei rmst be en indhfidual whIMQ ibabandoro hislher residential wall
or Town State Zip Code in accordance with 15A NCAC k-0113.)
4b.CONTACT PERSONiWELLOWNER. (r:CLYr T AaLarn s
rG 900t,f V� OLvr'lo p PRINTED NAME OF PERSON ABANDONING THE WE LL
NAME '
51-14 Doresv,IIc. 3�11-7 :
STREETADDR_SS QG P�� µ
fa
Submit a copy.to.the owner'aad the.original to CIMS10n:of Wate�'6ltuality-1Marimatlon Processing, Rerv.5/0 30
1617 Mail Service Center',Raleigh;NC 27689-1817,Phones(999)ti07;tEs300