Iredell_Well Abandonment_20240318

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\ 7)r WELL ABANDONMENT RECORD
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' North Carolina Department of linvironment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION## 4410q- G
1.WELL CONTRACTOR: 6. WELL DETAILS:
i oh n n it Cann n)yI a a.Total Depth 2.I� ft Diameter._ (p in.
W II Contractor(Individual)Name J b.Water Level(Below Measuring Point): 3S / ft.
'eD(fin toe-it brills‘'-9 • Measuring point is ( ft.above land surface.
Well Contractor Company Name c�
14-S 4D She r r i i is Fp r d t�-w 6. CASING: Length Diameter
Street Address /
. 1.1S bu r 9 nC- ` S j 4-'7 a Casing Depth(if known): 7‘ ft. Le in.
City or Town State Zip Code b.Casing Removed: 0 ft 0 in.
( G 4 ) L051, $ 61
' 7. DISINFECTION: 4 .M t K c-
Area code Phone number
(Amounts f 65%75%calcium hypochiorite used)
2.WELL INFfMATION:
8. SEALING MATERIAL:
SITE WELL ID# Of applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (it applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable)4bZto 45 53 4q Water _gal. Water gal.
)3entonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite . lb.
WELL USE(Check applicable use): Monitoring Residential
Type: urry Pellets
Municipal/Public Industrial/Commercial Agricultural Water __ gal. . ' - ,�
Recovery Injection Irrigation Cher. �4� '
tilgk
ki
Other(list use) Type material— brF.,„-,,a..;
8 ZOI�
,%P,a;,,
Amount F'I '^
3.WELL LOCATION: 4/4• - $i-
COUNTY I re-di i i QUADRANGLE NAME ' g
NEAREST TOWN: hrlD 0 r Q S"I I I G 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(S1ree11Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) 1�nrnPr et.
TOPOGRAPHC/LAND SETTING:
Slope Valley Flat Ridge Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
5- form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE .L _"33._!4 n"DMS OR 3X.XXXXXXXXIOD . in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE. 5.],�`'DVS OR 7X.XXXXXXXXIDD types of fill materialesed
Latitude/iongitu a source: BPS []topographic map Z i ' Z,Y�
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED 11
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 wet is located.Complete 4a; THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well,skip 4a;complete 4b,well owner information only.)
FACILITY ID# (if applicable)
NAME OF FACILITY siG OF c T► ELL C RACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City Cr Town State Zip Code (The private well owner must be an individual wpersongfyebandons hislher residential well
in accordance yr 15A NCAC .0113.)
4b.CONTACT PERSONIWELL OWNER: —1;; „V1 ymlrt:h
NAME .1e✓re rn 9 Osbo f m-A PRINTEDVAME OF P RSON ABANDONINt THE WE LL
STREET ADDRESS 3139 Ar..4.0 I&i.m ttbDresV i IIC,
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