Mecklenburg_Well Abandonment_20230213

i
,,,„ ..
,,,,srArf.;..._ _
.y: i ' ?ii-; WELL ABANDONMENT RECORD 1
Vt <r 1° North Carolina Department ofEnvirontuent and Natural Resources-Division of Rater Quality
WELL CONTRACTOR CERTIFICATION# '7 J6 9 - c '
i
1.WELL CONTRACTOR: - "' 6. WELL DETAILS:
JO in n n L n n t. a.Total Depth c;?IP ft. Diameter: in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): Z " ft.
*in W 0l51 1j30 t D r t II;it-9 Measuring point is I ', ft above land surface. :
Well Contractor Company Name L f I.
i(0 Shn rr i its FFo c A- (act 6. CASING: Length Diameter
Street Address
Sa.l i sbu.r4 D C a`3 14'••i a.Casing Depth(if known): /00 ft. 0 in.
City or Town - State Zip Code b.Casing Removed: ft. in.
( qbtl ) I03(p 9 7. DISINFECTION: /4 f'uZ
Area code Phorie number .
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION: '
• 8. SEALING MATERIAL:
SITE WELL ID It (if applicable) .
Neat_Cemept Sand Cement
STATE WELL PERMIT# (if applicable),
Cement - lb. , Cement lb.
COUNTY WELL PERMIT #(if applicable) I OD M 55.1 Water gal; Water gal.
_ Bentonite ' •
DWQ or OTHER PERMIT #(if applicable) .^� "'. 6.'..-
Bentonite lb.,,; ,° " Lr;
WELL USE(Check applicable use)EI Monitoring 'St: Residential ' r
Type:_ Slurry 0 Pellets . Is-,
2023
CI NIunIcipalIPublic i Industrial/Commercial 0 Agricultural Water 15U0 [[gal. FEB 1 c,
Other •r:��I�rC�.i ;^zg Unit
iy Recovery 0 Injection 0 Irrigation irr„�,;4f3•.4�, •
0 Other(list use) Type material `
Amount
3.WELL LOCATION:
COUNTY M 42-c- QUADRANGLE NAME ;'
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
NEAREST TOWN: MQ�ttlzKbLLrg '
Ci.taf t o-Ito ?utt'n f 421 ' r7roehjc I
(Street/Road Name,Number,Community.Subdasion,Lot No.,Parcel,Zip Code) ,
TOPOGRAPHC I LAND SETTING:
ri Slope Ct Valley CI Flat U 1 Ridged Other I
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theeli on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 9 2 '.Lei "DM O
5 OR 3X.XXXXXXXX D .In the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE75b8 _S il'f•4 "DMS OR7X.XXxXXXXXIDD types of fillmaterialsised
il
Latitude/longitude source: )]GPS ❑Topographic map 11. DATE WELL ABANDONED 1"- Z @"' 3
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) i.
I DO HEREBY CERTIFY THAT THIS 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 4a: THiS RECORD S BEEN POVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.) r- 1, _ ,
FACILITY 10#(if applicable) " ` G9"
73
NAME OF FACILITY ) REOF? eDI:O.:CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wbersonalhabandons bigot'residential ware
In accordance with 15A NCAC 2C.e1'13.)
4b.CONTACT PERSON/WELL OWNER: `Sp)10 h L_)-n t� i t et
NA Q TTV►Q.i0 ar 0 LL%t1
NAME Imo` PRINTED NAME OF PERSON ABANDONINGVHEINE LL
STREET ADDRESS 11 q 36 M011-1 0
aorneti-"• G GW30
Subm Form
it a copy to the owner and the original to:Division of Water Quality-Information'Processing, Rev. 6
1617 Mail Service Center,Raleigh,NC 27699-1617,Phone:[phone]