Davidson_Well Abandonment_20230213

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; '• Jr ' WELL ABANDONMENT RECORD
,� 1 `t' Nortlr.Carolina Department of Environment and Natural Resources Division of Water Quality
" WELL CONTRACTOR CERTIFICATION# 4-1-Lo q - 6
i
1.WELL CONTRACTOR: . - • 6. WELL DETAILS: % e�
LiDk f Yl q n Il I rt - aTotat Depth � ft. Diameter. 2 in.
Well Contractor(individual)Name b.Water Level(Below Measuring Point): 1 V ft
D Loan st.i3L IA "br i it i n-9 Measuring point is 0 ft.above land surface,:
Well Contractor Company Name
41 4-n Sh L rr i i i s i`t)rd_ sz 6t , 6. CASING: Length Diameter
Street Address /
Sc 1iSbu--r'� • he. agi4`1 a Casing Depth(if known): /Lift" ft , Z�' in.
City of Town State Zip Code b.Casing Removed: 1' it G ft in.
(rib* ) (03 to '7 B`l q 7. DISINFECTION:
Area code Phone number ;;
(Amountof 65%75%calcium hypochiorite used)
Z.WELL INFORMATION: 8, SEALING MATERIAL:
SITE WELL ID# (if applicable)
• Neat Camoat Rand.Cent8Dt
STATE WELL PERMIT# (if applicable)
Cement Ib. Cement lb.
COUNTY WELL PERMIT #(if applicable) F;(e- W 2 2 2 9 Water Gel. Water aal.
pentonite
DWG or OTHER PERMIT#(if eneticabie)
Bentonite ;,Ib.
WELL USE(Check applicable use)7 Monitoring % Residential a
Type: luny LIPellets ° �6 tc d
Q M unicipal1Public Cl IndustriaUCommerclal 0 Agricultural Water 700 ! 1 gal. ®�
Fte 1 -S: 2023
0 Recovery D Injection 0 Irrigation gther
Ci Other(fist use) Type material -ad 1 L In"orMal t Pry'' %gig&Mil
Amount /
3.WELL LOCATION: •
COUNTY D v i'(sen QUADRANGLE NAME • .
NEAREST TOWN: Lre11rn.e541en 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(StreetRoad Name,Number,Community.Subdivision,LotNO,.Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING: '
0 Slope 0 Valley 0 Flat Cl Ridge'D Other I
(Check appropriate setting) 10. WELL DIAGRAM:Draw a detailed sketch of ttteell on the back of this
35 42 3% N form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE "se "DMS OR 3X.X00cxl000 0D . in the well,gravel Interval,intervals of casing perforations,and depths and
LONGiTUDEge._,_"i4' 60 W .DMS OR7X.XXXXXXXX O types of fill materials,sed
1'
Latitude/longitude source: 036PS propographlc map 11. DATE WELL ABANDONED / —1 a— 23
(location of well must be shown on a USGS topo map andatiached to
this-form if not using GPS) i DO HEREBY CERTIFY THAT THIS ma WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACIU;Y•The name of the bushresewhere the Wall is located.Complete 4a r THiS RECORD HAS BEEN Pampa)TO THE WELL OWNER.
(ira residential well,skip 4a;complete 4b,Well owner Information only-) 'i A� `lj Z.3
FACILITY ID#(if appiicable) '�'' •
WE
NAME OF FACILITY SI RE OF DWELL CONTRACTOR DATE
STREET ADDRESS ' 1
\p?. SiGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well ownetraust be an individuatwlt irsonalhabarulons hislher residentlat well
in accordance` '15A NCAC C.0113.)
4b.CONTACT PERSONIWELL OWNER: dijt?y i h ylv II Cj
NAME ki -14 a Le-D ikt PRINTED NAME OF RSON ABANDONING WE LL
STREET ADDRESS i c I A rr o w it aac(- f F
l c i n&-1-a n, n t,.. . 1.I.
Submit a copy te the owner and the original to Dielsion.of WON;Quality=Infomtatlon Processing, Form GW-30
1617 Mail Service,Center;Raleigh;NC 27699.1017,Phone;(919)807.;6300 . . - • - Rev.5/10