Rowan_Well Abandonment_20230626

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y r' WELL ABANDONMENT RECORD
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y )"_ North Carolina Department of Environment and Natural Resources-Division of Water Quality
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WELL CONTRACTOR CERTIFICATION# a, ,2 2
- - 6. WELL DETAILS:
1.WELL CONTRACTOR: a.Total Depth i !' ' ft. Diameter: 4 in.
1 �.,�
Well C for(Individual)Name ' b.Water Level(Below Measuring Point): .2 S ft.
: Measuring point is r/ ft.above land surface.
Well Con rector Com any Name / /
6. CASING: Length Diameter
a.Casing Depth(if known): ft. in.
Street Address in.
Jo 5 !� � b.Casing Removed: �_ft.
City or Town State Zip Code
I �%7 I9 7. DISINFECTION: `
L a 2
Area code
ode Phone number - (Amount of 65%75°Jo calcium hypochiorite used)
2.WELL INFORMATION: ' 8. SEAUNG MATERIAL:
SITE WELL ID# (if applicable) ulna►cement Sand—Cement
STATE WELL PERMIT# (if appticable) Cement
lb. Cement lb.
UUater gal. Water Qai.
COUNTY WELL PERMIT #(it applicable) `�Q� d
gento»ite
DWQ or OTHER PERMIT #(if applicable)_-----_ Bentonite F [50 lb. b �r r
Fr'
WELL USE(Check applicable use)'` Monitoringi i Residential Type:✓Slurry >ipeliets
gal. ��N �, .3 2023
Ci M unicipal1Public i V IndustrialfCommerclal t:i Agricultural Water
Li Injection (sirrigationMgrt`7(G'Y.a•,•
:."3 Recovery t'+r'+�i=�"�`''
Type material
_I Other(list use)
Rmount
3.WELL LOCATION:
COUNTY_2= L� QUADRANGLE NAME g EXPLAIN M TH D OF EMPLACEMENT OF M TERIA L,J�`-
NEAREST TOWN: + U . /
Number,Community.Subdrvisan,Lot No..Parcel,Zip Code)
(StreeBRoad Name, �
TOPOGRAPHC t LAND SETTING:
":Slope f I Valley -_t Flat i tidge-1 Other
10. WELL DIAGRAM :Draw a detailed sketch of(Ewalt on the track of this
(Check appropriate setting) form showing total depth,depth and diameter of screens(if any)remainir
LATITUDE
In the well,gravel Interval,intervals of casing perforations,and depths an
LONGITUDE __
9��_�. ,� tJ "DM5 OR 3X.XJ�D 75 3-�•-'---1----3 DMS OR 7X.XXXXXXXX>0D types of fill materialsised
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Latitudeflongitude source: CEPS []ropographic map
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
this form if not using GPS) 1 00 HEREBY 2C, CON THIS WELL WAS ABANDONED IN ACCORDANCE
WITH ifiA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
THIS RECO HAS BEEN P/�VIDED TOTHE WELLC1tR't'iFJ2•
4a.FACILITY-The name of the business Where the well is located.Complete 4a: � � -�.r��
(If a residential well,skip 4a;complete 4b,well owner information only.) DATE
FACILITY{D# (if applicable). ` 1 b /Lick 5 t _ SI N URE C IFIED WELL CONTRACTOR
NAME OF FACILITY •�'� -
STREET ADDRESS I
SIGNATURE OF PRIVATE WELL OWNER ABANDONINbGTHE hamm
L DATE
City or Town Stateer re denf'+altse
Zip Code (The private well owner most be an individual wp oi(`in accordance with iNCAC 2C.0113.)
4b.CONTACT PERSONMIELL OWNER: PRINTED NAME F PERS N ABANDONING THE WE LL
NAME
STREET ADDRESS Form GW-30
Submit a copy to the owner and the original to:Division of Water Quality
Information Processing,. Rev.5/10
1617 Mail Service Center,Raleigh,NC 27699-1817,Phone:[phone]
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