Rowan_Well Abandonment_20230327

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/ ' �� WELL ABANDONMENT RECORD ;:
:4. ' ` North Carolina Department of Environment and Natural Resources-Division of Water Quality "
��_\ .:4. !� r _
WELL CONTRACTOR CERTIFICATION N J A MAR 2 i 2023
1.WELL CONTRACTOR: s. WELL DETAILS: �:IF�' y UR
'V
v dr/ /9L/Q .) t' a.Total Depth I,a‘ i ft. Diameter: G, in.
Well Cont ctor(Individual)Name b.Water Level(Below Measuring Point): 7 ft
>'L-JL, 0c J I.A i Measuring point is ' ft.above land surface.
Well Contractor Company Name J
£/g4/Z) shot r-I , ve/ /2 I 6. CASING: Length Diameter
Street Address
• AL- � �l rV 7 a.Casing Depth(it known): / a ft. in.
City or Town �
� : s =7 jS State Zip Code b.Casing Removed: ft. C.' in.
( ___ j 1/.3t .-• -1 '�-7 1 7. DISINFECTION: /9 6)L
Area a Phone number
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION:
8. SEAUNG MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Rent Camant
STATE WELL PERMIT# (if applicable) Cement lb. Cement lb.
� '
COUNTY WELL PERMIT #(if applicable)-3<) t I c2v2 0 - r Water gal. Wafer gal.
Sentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite 44.1/ lb.
WELL USE(Check applicable use}:' Monitoring Mr Residential
Type:eti urry :_i Pellets
M unicipallPublic i_• Industrial/Commercial '1 Agricultural Water i e, gal.
Recovery I_i Injection i. Irrigation flier
Other(list use) Type material_
Amount
3.WELL LOCATION:
COUNTY P..bL- rt QUADRANGLE NAME
NEAREST TOWN: `�/./, 16�
� //Le n? 9. EXPLAIN II*THOD OF EMPLACEMENT OF MATERIAL:
/ i'-fJM"/71-; >kit
(StreeURoad Name,Number,Conmim ty,Subdaris'.on,Lot No.,Parcel,Zep Code)
TOPOGRAPHC I LAND SETTING:
Slope i Valley • Flat _✓Ridge_'Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of thteell on the back of this
f form showing total depth,depth and diameter of screens(if any)remaini
LATITUDE 36 7.i� "rl]s�' 17 "OMS OR 3x.xx?xxXXX)OD in the well,gravel Interval,intervals of casing perforations,and depths ar
LONGITUDE
75� "DMO S OR7X.XXXXXXXxaD types of fillmaterialsrsed
, _.�.� IBC' _
Latitude/longitude source: DGPS [)Topographic map 11. DATE WELL ABANDONED c�(— 7 ^ ..?,;Z
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 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 i THIS RECORD S BEEN PRVIDED TO THE WELL OWNER.
(It a residential well,skip 4a;complete 4b,wed owner information orty.) C slC�
FACILITY ID N (if applicable) L.
�G LIRE odic TtP1ED WELL COMTF>]kQieR DATE
NAME OF FACILITY T _
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code w(The private ell owner must be an individual vkpmeelkabandons hislher residential we
in accor.Sgmatt 15A NCAC 2C.0113.)
4b.CONTACT PERSONIWELL OWNER:R / �jc�(� ,?9L�f_,'t�
NAME C s 5 L C. C(�r L � PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS Po 13c L log. P au:CYL Lk_ , r)e-
Submit a copy to the owner and the original to: Division of Water Quality-Information Processing, Form GW-30
1617 Mall Service Center,Raleigh,NC 27699-1617,Phone:[phone]
Rev.5/10

I.,.. Ir
STAr(„
Arr. .4; .it tic WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality .r 4`,t it
��,._ 2023
' WELL CONTRACTOR CERTIFICATION# 4 MAR 2 7
1.WELL CONTRACTOR: 6. WELL DETAILS: , 1 ,.• `,, -, -.
I L�CIA ` 1 c'!t�,�, ��S a.Total Depth 7 ft. Diameter: tC"
Weil Contras -(Individual)Name b.Water Level(Below Measuring Point): /ilf 7 ft
UL.utt v. b f 1 I v ,; Measuring point is / ft above land surface.
Well Contractor Company Name II
t-t g t 0 )e(1. I is �U r..t ICcJ' 6. CASING: Length Diameter
Street Address
(,, , / (L7 a.Casing Depth(if known): (l� ft. in.
• ow :.C, s �✓��� /� b.Casing Removed: ft. in.
City or Town 1 State Zip Code
()/3')• 4',J 6' 74�1 7. DISINFECTION: _ 7 Z
A ea code Phone number
(Amount of 65%75%calcium hypochiorite used)
2.WELL INFORMATION:
8. SEAUNO MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement sand Cement
STATE WELL PERMIT* (if applicable)
Cement lb. Cement lb.
�`yV a/�y
COUNTY WELL PERMIT #(if applicable) lY 7 / -/ Water gal. Water oar.
pentonite
DWG)or OTHER PERMIT #(if applicable)
Bentonite 16 6 ID.
WELL USE(Check applicable use)_' Monitoring i.' Residential Type:tortlurry _i Pellets
M unicipalUPublic i' Industrial/Commercial 'i Agricultural Water '(v C1 gal.
Recovery i_i Injection : Irrigation Other
.'i Other(Psi use) Type material
Amount
3.WELL LOCATION:
COUNTY Roc.,)LLa-t QUADRffANGIE NAME
NEAREST TOWN: CYt 1; 4 h 1f!7 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
13'ls Peeia.l' RA-1 j`)0 e.>7/1 6-,i_.'r4--
(StreetlRoad Name,Number,Commundy,Subdivis'.on,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
Slope Valley Flat iY Fr/idge_-'Other
(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_3tY�,�' 6 "DVMS OR 3x.XXxxXXXx)OD in the well,gravel Interval,Intervals of casing perforations,and depths and
LONGITUDE 75&-36' S"e) "DMS OR 7X.XXXXXXXXXID types of NI materlalsrsed
Latitude/longitude source: Q3PS Ofopographic map 11. DATE WELL ABANDONED 7 -,_1
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
VNTH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY.The name of the business Wier)the well is located.Complete 4a i THIS RECORD HAS BEEN PMVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner infomlation orty.)
FACILITY ID# (if applicable)
SIGNAT R.
ERT E WEL CONTRACTOR DATE
NAME OF FACILITY t
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL OATS
Zip Code (The private we.i owner must be an individual w abandons Ifs/her resilentlalwell
City Town State in accordance with 15A NCAC 2C.0113.)
4b.CONTACT
PERSON/WELL OWNER:
t_-[
NAME - -M 5 E t.t ef-E'_l t rr L L-` PRINTED NAME OF PERSON ABANDONING THE WELL
STREET ADDRESS PO 134)x l S v taw Ca:-If- nC-
Submit a copy to the owner and the original to: Division of Water Quality-Information Processing, Form GW-30
1617 Mall Service Center,Raleigh,NC 27699-1617,Phone:[phone]
Rev.5/10

47,,
srnrl... '
•
`'ter.' „ WELL ABANDONMENT RECORDtVl
iMA _
' - a North Carolina Department of Environment and Natural Resources-Division of Water Quality .*� tom,i.."' ` 1 I
s.
WELL CONTRACTOR CERTIFICATION# 07 4 MAR 2 7 2023
?ni'J+i-v;.v�,•,.t -ram„
1.WELL CONTRACTOR: s. WELL DETAILS: Q r� >' 3 rIg tj
—rod," cQ/0-) J a.Total Depth _3 () ft. Diameter- c.Y in.
Well Contr (Indivial)Natne b.Water Level(Below Measuring Point): .2—ft
04s%44.p / r// .Y, / Measuring point is_ C ft above land surface.
Well Contrac or Company N me LTV 6 $Jty,-1/4 I ✓ ,,v— ,� 6. CASING: Length Diameter
Street Address c/
S !! /r, G► p?'S/G/�7 a Casing Depth(if known): r�ri ft. 2 q in.
CifyGr��S b v 1L late / b.Casing Removed: ft. in.
( 7C df)TOw�n ?� �?S75 State Zip Code 7. DISINFECTION: e7r 1/
Area code Phone number
(Amount of 65%75%calcium hypochforite used)
2.WELL INFORMATION:
9. SEAUNG MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
• Cement lb. Cement lb.
COUNTY WELL.PERMIT #(if applicable) 3 9 I S i� - 1 Water gal. Water gal.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite lb.
WELL USE(Check applicable use):' Monitoring ;fr.-Residential Type: i Slurry :_i Pellets
M unicipallPublic ,_. IndustrialfCommercial '.i Agricultural Water gal.
Recovery !! Injection '., Irrigation giber
Other(tat use) Type material i /ctit t/
Amount �nC� *. /CIS
3.WELL LOCATION:
COUNTY.6 t,./C-t Pt QUADRANGLE NAME
NEAREST TOWN: SG7i'S 6 L t 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
i31�
r G' /-1P �j,C i'L. -/Pip r�i9� /— -7%r/
�¢i �� r'�rr•��r�p�
(Street/Road Name,Number,Cormnm3y,Subdivis`on,Lot No..Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
--:Slope ?VaLey Flat i_f4dge_.'Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of thtae:l on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 9 "DMS OR 3X.xxxxXXX)0oo in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE _
75��' '
30 5/ "DMS OR 7X.XXXXXXXXXiD types of NI materialsrsed
Latitude/longitude source: D3PS [(Topographic map 11. DATE WELL ABANDONED 7 3
(location of well must be shown on a USGS topo map endaftached to
this form if not using GPS) 100 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
VViTH 15A NCAC 2C, 'ELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a: THIS RECORD HA EN PMVIDEO TO THE WELL OWNER.
(If a residential weal,skip 4a;complete 41s.we:l owner information orty.)
FACILITY ID#(if applicable) ~ 7 2
SIGN T E OF C FLED L ONTRACTOR DATE
NAME OF FACILITY
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
Z Code (The private weli owner must be an individual v r5�9a rebandons hisfier residential well
City or Town State p in accordance wkh 15A NCAC 2C.0113.)
4b.CONTACT PERSONM}ELL OWNER: .j�i(/1 " 4O
NAME C -jLt SLC. PECLlF- LL'(_.. PRINTED MEOFPERSBANDO THE WE LL
STREET ADDRESS PD ROx(/ . PattO[/Q t-k , nC.--
Submit a copy to the owner and the original to: Division of Water Quality-Information Processing, Form W-30
1617 Mail Service Center,Raleigh,NC 27699-1617,Phone:[phone] Rev.

i
•.7,
.4 STArf.. .
,/. .ti-1 WELL ABANDONMENT RECORD
rg North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# :; 5 c; 2
1.WELL CONTRACTOR: . 6. WELL DETAILS:
1
(.1 61 /� C,y4 r,n s a.Total Depth .571 02 "ft. Diameter. in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point):_a 9 ft.
-R()tic:„ i : ) I ;Y- 4 Measuring point is r ft.above land surface.
Well Contractor Company me J Lt LI QU § C S c 1(. 1 I i 'Fc'/k i P�. 6. CASING: Length Diameter
Street Addres
a.Casing Depth(if known): C-- . ft. r2 in.
`� i 1 '7 State iP/o 1--/de 7 b.Casing Removed: ft. in.
City or Town( 7t ) 634, 7S W l` . 7. DISINFECTION: 7 C L
Ara codeod Phone number
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION: 8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable) Y? / 7 w ' Cement lb. Cement lb.
Water gal. Water gal.
COUNTY WELL PERMIT #(if applicable)
Qentonite -
DWQ or OTHER PERMIT #(if applicable)
Bentonite /3e lb.
WELL USE(Check applicable use) I Monitoring Residential Type: I Slurry ‘Pellets MAR 2 2023
M unicipaliPublic i_. Industrial/Commercial r; Agricultural Water 3 C. gal.
IrliJi'iY::d+•':'f' s)'',-• 3"::7:ig Cr',a
Recovery li, injection i_ Irrigation Other
�'
li Other(fist use) Type material
Amount
3.WELL LOCATION:
COUNTY P[X.,.)r...- QUADRANGLE NAME
NEAREST TOWN: 561!.S4 L J 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
I 396 'PGA 1.F - Pry
7 �� rn ,r. 1/ Po J./
(Street/Road Name,Number,Community,SubdivisIn,Lot No..Parcel,Zip Code)
TOPOGRAPHC I LAND SETTIINGG;
Slope -i Valley - Flat +,(Ridge_)Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of thaell on the back of this
form showing total depth,depth and diameter of screens Of any)remaining
LATITUDE 36_3 S-31,,2 42 5- "OMS OR 3X.XXXXXXXX)OD in the well,gravel Interval,intervals of casing perforations,and depths and
,glL"��
LONGITUDE
7�J q 7 DMS OR" 7X.XXxxXXXXat)D types of fill materialsrsed
� Q
Latitude/longitude source: COPS Otopographic map 11. DATE WELL ABANDONED 8 c7?-
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 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 RECOR•HAS BEEN PBVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,wet owner information only.) / p
FACILITY ID# (if applicable) s4N: .RE OKRT1FtE LL CONTRACTOR DATE
NAME OF FACILITY
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
State Zip Code (The private well owner must be an individual wpersonaltebandons hisTher residential well
City or Town in accordance wth 15A NCAC 2C.0113..)
4b.CONTACT PERSON/WELL OWNER: / 5 1 f - ,41;, 1 i
NAME C 14 -AA SE LC Peek( LL C, PRINTEDNAMEOFPERSONANDOTHEWELL
STREET ADDRESS Po !. X. loA, i PLO C(t i_It_ n c
Submit a copy to the owner and the original to: Division of Water Quality-Information Processing, Fov.5/10 GW-30
1617 Mail Service Center,Raleigh,NC 27699-1617,Phone:[phone]