Duplin_Well Abandonment_20230602

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f o -• _ WELL ABANDONMENT RECORD
g' North Carolina Department of Environment and Natural Resources-Division of Water Quality
",,,,,:.`,`,....0' WELL CONTRACTOR CERTIFICATION#
1.W bL CONTRACTOR: 5. WELL DETAILS:
0.V 1 LRe 1 er a.Total Depth: Z 410 ft. Diameter: 2- in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): S8 ft.
Re q ;s-J-et W el I Co • Measuring point is i ft.above land surface.
Well Contractor Company Name A ' ► 1- ,STREET ADDRESS 721 W es-� C � PA• 6. CASING: Length Diameter
Tlo.re 1 i)I N.C.- Zg q'&O a.Casing Depth(if known): NIA ft. 2- in.
City or Town State Zip Code b.Casing Removed: ft. in.
( 9Ib )- U —31y51 Area code-Phone number 7. DISINFECTION: 3 oz. 1}I y+r`T7
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) . • . Neat Cement Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(if applicable)
Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): 0 Monitoring Eesidential •
Bentonite I fD lb.
❑ Municipal/Public 0 Industrial/Commercial 0 Agricultural Type:0 Slurry ellets 7"" ,-,�'.r r
pp t
❑ RecoveryIrrigationWater gal. ; r:b...%a L r 4>..r
0 Injection 0
• Other l�II N Cf 2 2023
❑Other(list use) J
Type material
IrliSi t, Alt Pt:'t:: ;'�.:r7 Un'�
3.WELL LOCATION: Amount C'NC.: ut .;
COUNTY lU()I I IN QUADRANGLE NAME
NEAREST TOWN: e J1 al\ t/I`� •/( I e. .. ' 9. ,'EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) - • TPP M/d ,'-r d 1,0 e I/ iJ 11T 1 I TV 1 1
TOPOGRAPHIC/LAND SETTING:
❑Slope 0 Valley lat 0 Ridge❑Other
• (Check appropriate setting)
. 10. .WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATITUDE 35. 0/5920 May be in degrees, form showing total depth,depth and diameter of screens(if any)remaining
minutes,seconds or in a —in-the-well,--gravel interval,intervals of casing perfoiattons,andaepT]ts and
LONGITUDE _ • SZ- __�7 decimal format •
types of fill materials used.
Latitude/longitude source: GPS 0 Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED 5Z.3
attached to this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business where the well is located.Complete 4a and4b., I WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(If a residential well,skip 4a;complete 4b,well owner information only.) • , THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable) .--A, (� ,,
NAME OF FACILITY
SIGNATURE r/j�T/�1 23
SIGNATURE OF CERTIFIED W'ZI7IrONTRACTOR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL'/ OWNER: in accordance with I5A NCAC 2C.0 113.)
NAME CDI by 770IIt'jaltr [ J� Do►V1d L' }fi t` e/
STREET ADDRESS /y-7 fleer H O d i Pp.
PRINTED NAME OF PERSON ABA ONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5/06

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