WQ0000601_Well Abandonment_20131105

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1. WELL CONTRACTOR:
L. Martin Shaver
Well Abandonment Record
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WF.T,L CONTRACTOR CERTIFICATION # 2986 A
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 324 Fields Drive, Suite C
Aberdeen NC 28315
City or Town State Zip Code
910 944-3140
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) MW#1
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check Applicable Box) Monitoring ® Residential ❑
Munici.pal/Public ❑ Industrial/Commercial ❑ Agricultural ❑
Recovery ❑ Injection ❑ Irrigation ❑
Other (list use)
3. WELL LOCATION:
COUN TY: Richmond QUADRANGLE NAME
NEAREST TOWN: Hamlet
157 Campbell road 28345
(Street/Road Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC/ LAND SETTING:
❑Slope []Valley ®Flat []Ridge ❑ Other
(check appropriate setting)
LATITUDE 340 54.' 872 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 790 89.' 299 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitudesource: ®GPS ❑ Topographic map
(Location ofwell must be shown an a USGS taps map and attached to
this form if not using GPS)
4a. FACILITY- The name of the business where the well is located. Complete 4a and 4b. (If a
residential well, skip 4a; complete 4b well owner information only)
IC, FACIILITY ID k (if applicable) CSX .
NAME OF FACILITY CSX Waste Water Treatment Plant
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
4b. CONTACT PERSONAVELL OWNER:
NAME CSX
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
Area Code — Phone number
5. WELL DETAILS:
a. Total Depth 50 ft. Diameter: 4" in.
b. Water Level (Below Measuring Point): 38 ft.
Measuring point is 0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): 40 ft. 4 in.
b. Casing Removed: 0 ft. 4" in.
7. DISINFECTON:3.23
(Amount of 65%- 75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb
Water gal. Water gal.
Bentonite
Cement I lb
Type: Slurry ❑. Pellets
Water gal.
Other
Type material
Amount _
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured Bentonite pellets In well slowly to ensure
proper sealing of well —
10. WELL DIAGRAM: Draw a detailed sketch oe CSellbtck of this
form showing total depth, depth and)diameterlof screens (if an) emaining
in the well, vel interval, intery lcasitigspei% rations , and depths and
types of fill material used. Y`7 "t° TF ",try tiie a��11G
11. DATE WELL ABANDONED 111412013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
111512013
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELLOWNER ABANDONING THE WELL DATE
(The private well owner must bean individual who personally abandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL ��pp PH
'
L��i�`�4Y
Submit a copy to the owner and the original to the Division of Water Quality within 30 days.
Attn: Information MgL,1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] ext 568.
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Form GW6,-30
Rev.

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I. WELL CONTRACTOR:
L. Martin Shaver
Well Abandonment Record
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2986 A
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 324 Fields Drive, Suite C -
Aberdeen NC 28315
City or Town State Zip Code
91( 0 )- 944-3140
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) MW#2
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check Applicable Box) Monitoring ® Residential ❑
Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑
Recovery ❑ Injection ❑ Irrigation ❑
Other (list use)
3. WELL LOCATION:
COUNTY: Richmond QUADRANGLE NAME
NEARESTTOWN: Hamlet
157 Campbell road 28345
(Street/Road Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
[]Slope ❑Valley ®Flat ❑Ridge ❑ Other
(check appropriate setting)
LATITUDE 340 54.' 784 ° DMS OR 3X.XXXXXXXXX DD
LONGITUDE 790 89.' 499 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: '®GPS ❑ Topographic map
(Location of well must be shown on a USGS topo map and attached to
th&form if not mvingGPS)
4a. FACILITY- The name of the business where the well is located. Complete 4a and 4b. (If a
residential well, skip 4a; complete 4b well owner information only)
sFACI1LITY•ID#(ifapplieabl-) ,CSX
NAME OF FACILITY CSX Waste Water Treatment Plant
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAME CSX
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
Area Code — Phone number
S. WELL DETAILS:
a. Total Depth 39' ft. Diameter. 4" in.
b. Water Level (Below Measuring Point): 29' ft.
Measuring point is 0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): 29 ft. 4 in.
b. Casing Removed: 0 ft. 4" in.
7. DISINFECTON:3.2
(Amount of 65%- 75%calcium hypochlorite used) .
8. SEALING MATERIAL:
Neat Cement
Sand Cement
Cement
lb. Cement lb
Water
gal. Water gal.
Bentonite
Cement
lb
Type: Slurry ❑
Pellets
Water
gal.
Other
Type material
Amount _
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured Bentonite pellets In well slowly to ensure
proper sealing of well.
14
'1P
10. WELL DIAGRAM: Draw_ a detailed sketch ofthe we "&,? all ih SrR ac
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gavel interval, intervals of casing perforations, and depths and
types of fill material used.
11. DATE WELL ABANDONED 11/412013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
11/512013
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE NVELLOWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
In accordance with 15A NCAC 2C .0113.) -
PRINTED NAME OF PERSON CONSTRUCTING THE WELL '
DENR®
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn: Information Mgt,1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] cat 568. Rev. 5/04�)} � g

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1. WELL CONTRACTOR:
L. Martin Shaver
Well Contractor (Individual) Name
Well Abandonment Record
North Carolina Department of Environment and Natural Resources- Division of Water Quality
American Environmental Drilling, Inc
WELL CONTRACTOR CERTIFICATION # 2986 A
Well Contractor Company Name
STREET ADDRESS 324 Fields Drive, Suite C
Aberdeen NC 28315
City or Town State Zip Code
910 944-3140
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) MW#3
STATE WELL PERMIT# (ifapplicable)'
COUNTY WELL PERMIT # if applicable)
DWQ or OTHER PERMIT it (if applicable)
WELL USE (Check Applicable Box) Monitoring ® Residential ❑
Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑
Recovery ❑ Injection ❑ Irrigation ❑
Other (list use)
3. WELL LOCATION:
COUN TY: Richmond QUADRANGLE NAME
NEARESTTOWN: Hamlet
157 Campbell road 28345
(Street/Road Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope []Valley ®Flat ❑Ridge ❑ Other
(check appropriate setting)
LATITUDE 34' - 54.' 882 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE 790 89.' 426 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitudesource: ®GPS ❑ Topographic map
(Location of well must be shown on a USGS ropo map and attached to
this form ijnot usingGPS)
4a. FACILITY- The name of the business where the well is located. Complete 4a and 4b. (If a
residetitial well, skip 4a; complete 4b well owner information only)
FACIILITY 1D (i�f appli�cab� .CSX
NAME OF FACILITY CSX Waste Water Treatment Plant
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
4b. CONTACT PERSONIWELL OWNER:
NAME CSX
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
Area Code — Phone number
5. WELL DETAILS:,
a. Total Depth 43 ft. Diameter. 4" in.
b. Water Level (Below Measuring Point):. 39. ft.
Measuring point is 0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): 33 fL 4" in.
b. Casing Removed: 0 ft. 4" in.
7. DISINFECTON:3.8
(Amount of65%- 75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb
Water gal. Water gal.
Bentonite
Cement lb
Type: Slurry ❑ Pellets
Water gal.
Other
Type material
Amount
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured Bentonite pellets In well slowly to ensure
proper sealing of well.
sA e � nnqqpp ' isjj6> �'�'�._.
10. WELL DIAGRAM: Draw a detailed sketrR'Yf f �;lvell,bn�the,backpft)�i
form showing total depth, depth and d�'amoe�r;oec�'s4(it3anyj r�emtai�iu>
in the well, gravel interval, intervals of casing perforation's`; ati� deptlis?��1��t�D y
types of fill material used.
11. DATE WELL ABANDONED 11/412013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
11/5/2013
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELLOWNER ABANDONING THE WELL DATE
(The private well owner must be ati individual who personally abandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
DR—F
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form G�,WQ�-30
AUn: Information Mgt.,1617 Mail Service Center- Raleigh, NC 27699-1G17, Phone No. [phone] ext 568. Rev. 6 �l U

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Well Abandonment Record
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2986 A
1. WELL CONTRACTOR:
L. Martin Shaver
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 324 Fields Drive, Suite C
Aberdeen NC 28315
City or Town State Zip Code
910 944-3140
Area code- Phone number.
2. WELL INFORMATION:
SITE WELL ID 9 (if applicable) MW#44
STATE WELL PERMIT#(ifapplicable) .
COUNTY WELL PERMIT # if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check Applicable Boa) Monitoring ® Residential ❑
Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑
Recovery ❑ Injection ❑ Irrigation ❑
Other (list use)
3. WELL LOCATION:
COUN TY: Richmond QUADRANGLE NAME
NEARESTTOWN: Hamlet
157 Campbell road 28345
(Street/Road Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ®Flat ❑Ridge ❑ Other
(check appropriate setting)
LATITUDE 340 54.' 804 'DMS OR 3X.XXXXXXXXX DD
LONGITUDE 790 89.' 404 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ®G PS ❑ Topographic map
(Location ofwell must be shown on a USGS topo map and attached to
thisform if not usingGPS)
4a. FACILITY- The name of the business where the well is located. Complete 4a and 4b. (Ifa
residential well, skip 4a; complete 4b well owner information only)
FACIILITY ]D # (if applicable) .CSX'
NAME OF FACILITY CSX Waste Water Treatment Plant
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAME CSX
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
Area Code —Phone number
5. WELL DETAILS:
a. Total Depth 45 ft. Diameter. 2" in.
b. Water Level (Below Measuring Point): 21 ft.
Measuring point is 0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): 35 ft. 2" in.,
- b. Casing Removed: 0 ft.- 2" in.
7. DISINFECT0N:3.12
. (Amount of 65%- 75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Sand Cement
Cement
lb. Celnent lb
Water
gal. Water gal.
Bentonite
Cement
lb
Type: Slurry ❑
Pellets
Water
gal.
Other
Type material
Amount
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured Sentonite pellets In well slowly to ensure
proper sealing of well.
A�! �R g(1_Iti -
►N iffiR IIIAMISEVj�� 1Oj`j 7
10. WELL DIAGRAM: Draw a detailed sketdi fifth we�� on the back ofthts
form showing total depth, depth and diameter of -screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill material used.
11. DATE WELL ABANDONED 1114/2013
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
11/512013
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELLOWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL D R
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW - ��Q
Attn: Information Mgt.,1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] ext 568. Rev. 5/06 tl W

1/5

r.,
Well Abandonment Record
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2986 A
I. WELL CONTRACTOR:
L. Martin Shaver \
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 324 Fields Drive, Suite C
Aberdeen NC 28315
City or Town State Zip Code
10 944-3140
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) [-MW#-5
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # if applicable)
-DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check Applicable Box) Monitoring ® Residential ❑
Municipal/Public ❑ Industriat/Commercial ❑ Agricultural ❑
Recovery ❑ Injection ❑ irrigation ❑
Other (list use)
3. WELL LOCATION:
COUN TY: Richmond QUADRANGLE NAME
NEAREST TOWN: Hamlet
157 Campbell road 28345
(Street/Road Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ®Flat ❑Ridge ❑ Other
(check appropriate setting)
LATITUDE 340 54.' 941 "DIVISOR 3X.XXXXXXXXX DD
LONGITUDE 790 89.' 231 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ®GPS ❑ Topographic map
(Location ojwe// must be shown on a USGS topo map and attached to
this farm if not usingGPS)
4a. FACILITY- The name ofthe business where the well is located. Complete 4a and 4b. (If a
residential well, skip 4a; complete 4b well owner information only)
TACIILITY ID #'(if applicable) ''CSX
NAME OF FACILITY CSX Waste Water Treatment Plant
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town Stale Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAME CSX
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
Area Code - Phone number
5. WELL DETAILS:
a. Total Depth 50 ft. Diameter. T' in.
b. Water Level (Below Measuring Point): 30 ft.
Measuring point is 0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): 40 ft. 2" in.
b. Casing Removed: 0 ft. 2" in.
7. DISINFECT0N:3.1
(Amount of 65%- 75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb
Water gal. Water gal.
Bentonite
Cement lb
Type: Slurry ❑ Pellets
Water gal.
Other
Type material
Amount
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured Bentonite pellets In well slowly to ensure
proper sealing of well,
• u td'Si ti�:4�v4wljr��,@ 9 i ��;�! z��3�
�f�6�t�.l,t?��n���i6lir 3;1m31.
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of thts
form showing total depth, depth and diameter of icreens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill material used.
11. DATE WELL ABANDONED 11/4/2013
t DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNTR.
111512013
SIGNATURE OF CERTI ED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE \VELLOWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
In accordance w$h 15A NCAC 2C .0113.)
PRINTED NAME OF PERSON CONSTRUCTING THE
Submit a copy to the owner and the original to the Division of Water Quality within 30 days.
Attn: Information Mgt.,1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] ext 568.
ANWIJ t!
Rev. 5/06

5
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.
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Well Abandonment Record
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2986 A
1. WELL CONTRACTOR:
L. Martin Shaver
Well Contractor (Individual) Name
American Environmental Drilling, Inc.
Well Contractor Company Name
STREET ADDRESS 324 Fields Drive, Suite C
Aberdeen NC 28315
City or Town State Zip Code
91t 0 ) 944-3140
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) MW#7
STATE WELL PERMIT 9(ifapplicable)
COUNTY WELL PERMIT # if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check Applicable Box) Monitoring ® Residential ❑
Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑
Recovery ❑ Injection ❑ Irrigation ❑
Other (list use)
3. WELL LOCATION:
COUNTY: Richmond QUADRANGLE NAME
, NEAREST TOWN: Hamlet
157 Campbell road 28345
(Streel/Road Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ®Flat ❑Ridge ❑ Other
(check appropriate setting)
LATITUDE 340 54.' 725 "DIVISOR 3X.XXXXXXXXX DD
LONGITUDE 790 89.' 778 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ®GPS ❑ Topographic map
(L. cation oftvell must be shown on a USGS tnpo map and attached to
thisform if not using GPS)
4a. FACILITY- The name ofthe business where the well is located. Complete 4a and 4b. (If a
residential well, ship 4a; complete 4b well owner information only)
FACIIGITY ID # (tfappIicable) CSX
NAME OF FACILITY CSX Waste Water Treatment Plant
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
4b. CONTACT PERS0NAVELL OWNER:
NAME CSX
STREET ADDRESS 157 Campbell road
Hamlet NC 28345
City or Town State Zip Code
Area Code — Phone number
5. WELL DETAILS:
a. Total Depth 35 ft. Diameter: 2" in.
b. Water Level (Below Measuring Point): 21 ft.
Measuring point is 0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): 25 ft. 2" in.
b. Casing Removed: 0 ft. 2" in.
7. DISINFECT0N:3.07
(Amount of 65%- 75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement ' lb
Water gal. Water gal.
Bentonite
Cement
lb
Type: Slurry ❑
Pellets
Water
gal.
Other
Type material
Amount
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Poured Bentonite pellets In well slowly to ensure
proper seallng of well.
IVI ` o L
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill material used.
11. DATE WELL ABANDONED 111412013
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
111512013
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
X
SIGNATURE OF PRIVATE WELL0IVNER ABANDONING THE WELL DATE
(the private well owner must be an individual who personally abandons his/her residential well
In accordance with 15A NCAC 2C .0113.) Eg P ®,•' •
PRINTED NAME OF PERSON CONSTRUCTING THE WELL A" 04i 1 U
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn: Information Mgt.,1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] ext 568. Rev. 5/06

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