Pitt_Well Abandonment_20231215

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• ¢14.s90 • J
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r.., •.., WELL ABANDONMENT RECORD
.� 11
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North Carolina Deparhaeat of Environment and Natural Resources-Division of Wafer Quality a ; ar ` '
�• """'`s WELL CONTRACTOR CERTIFICATION# , 43 ' / i. D(C 1 .. q ry 1.WELL CONTRACTOR: "m . 5. WELL DETAILS: • I `1 <�`3
nf?u V 1►'J t p a.Total Depth I R Diameter. Din:t,..h "�•':3 i_of..
J_ Well Cont4actor(Individual) e b.Water Level(Below Measuringft.Point):
111' . e v1 OP f/ Dr!'//11/) Measuring point is / i. ' IL above land surface.
4/Wellactor Company Name�� l Loop
+ ors /7Fr•/I 6. CASING: ' Length Diameter
Street Address
�f4
'nk Aril
�I _WC5`7? a.Casing Depth(rfimown): ��U ft. in.
City or Town State• Zip Code b.Casing Removed: 6 ft. in.
ELL 90• . 389B ) f
Area code Plitine number 7. DISINFECTION: �i72 �A/d'//-
_ z iNI:LL INFORMATION:-___ • _ - (Amount of 65%75%calclu m hypochlorite used)____ ___ --
SITE WELL ID 0(ifapplcable)_ 8. SEALING MATERIAL:
NeatCerent San ement
STATE WELL PERMIT# (If applicable)
•
Cement . lb. . Cement lb.
COtINTYWELLPERMIT #(ifapplicable) Water _gal. Water- gal.
DWQ or OTHER PERMIT*Of applicable) Bent oni?e
WELL USE Check a Gable use Bentonite ISri lb. .
( pp )FJ,Monitoning•,.....1 '1 sidentlal . _.
• -• . ' -Type:❑Starry ts`---._..:'_: . __. .._ ... _... _
❑ NIunieipal/Publlc' 0 IndustrtaUCommercial ❑ Agricultural Water gal.
D Recovery 0 Injection ❑ Imgation ..
• -- _ •- --. Other.
❑Other(list use) -- . _--- Type material
3.WELL LOCATION:
COUNTY'P.;14 . --- -OUADRANGIE NAME . '
NEARESTTOWN:- 4 t'^. • • 9. ' EXPLAIN M t T OD OF EMPLACEME OF MATERIAL:• -• g665` totr �Lt/!tilt 41• 2�f/3 /• w •
-
/Ii / e-(f.: ' w1 41 • ti.e..a'..r/,e
(Street/Road Name.N fiber,Community.Subdivision.Lot No.,Parcel,Zip Code)
• TOPOGRAPIjC/LAND SETTING:
0 Slope 0 Valley 1 0 Ridge❑Other
(Check appropriate setting) . . 10: WELL DIAGRAM:Draw a detailed sketch of theetl on the back of this - __ ______
- ' -- - - Torn:I showing Iota!depth;depth and trameter of screens(If any)remaining
LATITUDE •,,l •,____c U 'DMS OR 3X.OO0000000D In the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 7- -3 3?•DMS OR 7X.)000OOCCkDD types of fill materialssed
•Latitudefongitude source: L S Dropographic map 11, DATE WELL ABANDONED V J 3`,_ `(}3
(location of well must be shown on a USGS topo map andattached to
this farm if not using GPS)
100 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE•
WITH ISA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF 4a.FACILITY-Ttie name of the business where the well is located.Complete 43 t THIS RE
C RD HAS BEEN POVIDED TO THE WELL OWNER.
(Ira residential well,skip 4a;complete 4b,well owner information only.) I
FACILITYID.#-(rfapplicable) ' fI-3 d d3
.NAME OF FACILITY' S ATURE 0 CE SD WELL CONTRACTOR [ DATE
SIREETADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town . .State -_ Zip Code (The private well owner must be an Individual wilersonallyabandons hislberresidentsl well
,n as enca wNh 1EA C 2C.0113:)=,
4b.CONTACT PERSONAYJ1�LL O)NNEFb rf //^^/I
NAME..5d A/• t •.I Arm y PRINTED NA E OF PERSON 1DONINcc G WELL -
STREETADDRESS 4I t 1� c L 0IA n'f Nola C ko
"`1 '1:119na- ,- :9_`r . a e--� ,= � p. rrx .'`>1a1 ', o a o"%� Z l�j Form
.—. 1. _- i;r ._: ''1'1'l 4 .• 4, JY. t`-9,s i$ rpp T ' 3 s •
rm GW-30
Rev.5110