Rowan_Well Abandonment_20231229

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+. r�, -i - WELL-'ABANDONMENT RECORD
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RI North Carolina Department of Environment and Natural Resources-Division of Water Quality
=`"- WELL CONTRACTOR CERTIFICATION# Z 5 22_
1.WELL CONTRACTOR: 6. WELL DETAILS:
a C,la lrn S _ a.Total Depth 49 i ft. Diameter. 02 In,
Well Contractor(Individual}Name b.Water Level(Below Measuring Point): g.2- ft.
'_0 W civ' W o_) t 11)r i I 1 i Measuring point is / ft.above land surface.
Well Contractor Company Name Len th Diameter
1VS 4 b Shev v r i 1ls fD r �-4 6. CASING: 9
Street Address C ,d$) ,1 a Casing Depth(if known): --�--ft. in.
Sa r.TOWn y; b.Casing Removed: /' ft. 4 in.
City'or Town State zip Code /
/Y 04 ) 103(a q.?4 7. DISINFECTION: 6'4/0/:.4',-P
Area code Phpne number (Amount o1.65%75%calcium hypochlorite used)
2.WELL INFORMATION: 8. SEALING MATERIAL:
SITE WELL ID# (if applicable) SAnd Cement
NgaLCement• -
STATE WELL PERMIT# (if applicable) Cement lb. Cement ib-
Water gal. Water aal.
COUNTY WELL PERMIT #(if applicable)
399 12
Bentonite
DWQ or OTHER PERMIT#(f applicable) Bentonite 156 lb. a s .,..
WELL USE(Check applicable use}3 Monitoring sidential Type:L Slurry ellets F —e ��
D
❑ M unicipallPublic 0IndustriaUCommercial 0 Agricultural Water j gal. DEC 2 9 2023
I] Recovery 0 Injection U Irrigation Other .
kilo :ien Prr-;::9eotx9 Utz
©Other(IiSCuse) Type material. wVr•-
Amount
3.WELL LO TION:
COUNTY OWon QUADRANGLE NAME
NEAREST TOWN: SertTs
. 9 RoC )4 j i 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
""'" 1
(StreetlRoad Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC I LAND SETTING:
D Slope I]Valley 0 Flat 0'Ridge0 Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of tlwell on the back of this
form showing total depth;depth and diameter of screens(if any)remaining
LATITUDE 36 V'.5.2Setk "DMS OR 3xago 00000DD in the well,gravel interval,Intervals of casing perforations,and depths and
LONGITUDE 75t6. . "DMS OR 7X.m00000( ID .types of fill matedalsised
/Q�? � `�O '2�
Latitude/longitude source: QGPS Dropographic map 11. DATE WELL ABANDONED )
(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 NCAC2C,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 residentiatweil,skip 4a;complete 4b,well owner information only.) 1 ��() z_3
FACILITY ID#(if applicable) , E nE D LLcoN ActOR DATE
NAME OF FACILITY STREET ADDRESS / (Cj
s'o v's "r
,54/'>!u� e-- aSYW SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
6' State Zip Code (The private well owner must be an individual w iiersonali ebandons hisliier residential well
City or Town in accordance with 15A NCAC 0113,) 123
4b.CONTACT PERSONIWEL//L OWNER: ', d, ' hiAs/yj f L
NAME c/1//4/ f-Pl�l a/ PRINTED NAME OF PE S N ABANDONING THE WE LL
STREET ADDRESS'? q 0 ft W t i Ea , VD C" e-i 1
Submit a copy 0:the owner and the:original to.Division Of Water Quality=InformationForm GW-30
Processing, Rev. GVV
:1611 Mail Service Center,Raleigh,.NG 27699•1617,Phone.;[phone]..