Stokes_Well Abandonment_20230327

WELL ABANDONMENT RECORD
' a North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3308-A
1.WELL CONTRACTOR: 5. WELL DETAILS:
Raymond Brown IV a.Total Depth A, s _ft. Diameter: � in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): ft.
Raymond Brown Well Company Measuring point is i a ft.above land surface.
Well Contractor Company Name
1109 N Main St PO Box 337 6. CASING: Length Diameter
Street Address ,�
Danbury NC 27016 a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
33L 6 ) 593-8239 (,
Area code Phone number 7. DISINFECTION: 8 1)
(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)
Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) Water gal. Water gal.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite lb.
WELL USE (Check applicable use): Monitoring Residential ; _
Type:'- Slurry Pellets
Municipal/Public Industrial/Commercial C: Agricultural Water al.g MAR
Recovery _ Injection ❑ Irrigation Other 2023
Other(list use) Type material
Amount
3.WELL LOCATIO
COUNTY t 5 QUADRANGLE NAME
NEAREST TOWN:
,� f 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) ;j)
TOPOGRAPHC/LAND SETTING: I
4
I ' Slope Valley L Flat ❑ Ridge[] Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 36 °�'_ "DMS OR DD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 75 0° "DMS OR DID types of fill materialsised
Latitude/longitude source: ❑GPS E]fopographic map f ZZ
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
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 RECORD
%HAS
BEEN Pq�LJPED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable)
NAME OF FACILITY SIGNATURE OF CERTIFIED WELL 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 wtersonall bandons his/her residential well
: in accordance with 15A NCAC 2C.0113.)
41b.CONTACT PERSONIWELL OWNER:
NAME 5D,p 8 P10 fl -a : PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS
Submit a copy to the owner and the original to: Division of Water Quality- Information Processing, Form GW-30
1617 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone] Rev.5/10