Rowan_Well Abandonment_20240318

sT t WELL ABANDONMENT RECORD
�'3 L. q
North Carolina Department of Environment and Natural Resources-Division of 1V, Quality
4„ WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR: 5. WELL DETAILS: i
��
J h y-)n (t_yl h y�C1 a Total Depth u _ft. Diameter In.
Well Contractor(individual)Name
b.Water Level(Below Mea:unng Point) 'S D Y ft
QY i 1 1 y� Measuring point is 'De� t above land surface.
k 0 L,��o We-it
Well Contractor Company Name
y$yo Shir r i I I s Fl , �1 }z tl 6. CASING: Length Diameter
Street Address ft. in.
j
a.Casing Depth(if known) �_
"t I I S�LL►`i b Casing Removed: �°H C ft in.
City or Town State Zip Code
('70 tj ) (p .3(a �5 r� 7. DISINFECTION: [vr f A c-
Area code Phqne number
(Amount of 65%75%calcium hypochlorite used)
2.WELL INFORMATION: g, SEALING MATERIAL:
SITE WELL ID# (if applicable)
Npat Cement Sand Cement
STATE WELL PERMIT# (if applicable) Cement Ib. Cement lb.
Water cal Water aal.
COUNTY WELL PERMIT #(if applicable)
DWQ or OTHER PERMIT #(if applicable) V L/
Bentonite lb.
WELL USE (Check applicable use). Monitoring Y Residential Type:."'lur Pellets
ry NIP.K i Zd24
M unicipallPublic ClIndustrial/Commercial Agricultural Water bo 1 gal.
VAE
Recovery ;-_i Injection Irrigation Other
Other(hst use) Type material
Amount 20 <
3.WELL LOCATION:
COUNTY OLu�n QUADRANGLE NAME
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
NEAREST TOWN.
(StreetlRoad Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) _
TOPOGRAPHIC f LAND SETTING. —
Slope ' Valley _' Flat [1 Ridge'_ Other
(Check appropriate setting) 10. WELL DIAGRAM Draw a detailed sketch of ttw,eil on the back of this
0 104 form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE _ ___ DMS OR 3X.XXXXXXXX)0D in the well,gravel interval, intervals of casing perforations,and depths and
55. MS OR 7X.XXXXXXXX»p 4�D types of fill materials sed
LONGITUDE__°_•
Latitude/longitude source: QGPS Qiopographic map 11. GATE WELL ABANDONED aZ—/S- 7.9
(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 NCAC 2C,WELL CON 3TRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a h : THIS RECORD HAS BEEN PBVIDED TO THE WELL OWNER
(if a residential weN,skip 4a;complete 4b,well owner intomha!on only.) �� Z—1 5+Z
FACILITY ID# (if applicable) —���-�
SIGN A OF CE FIED CONTRACTOR
DATE
NAME OF FACILITY
STREET ADDRESS —
• SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
State Zip Code (The private well owner must be an individual wpersonalpbandons his/her residential well
City or Town in accordance with 15A NCAC 2C.0113.)
4b.CONTACT PERSON(WELL OWNER:
NAME
C,L r k W0.1 t 2(S PRINTED NAME C) PERSON PBANDO G THE WE ILL
STREET ADDRESS�5
S0.1i�hLlrci nC'•
Submit a copy to the owner and the original to: Division of Water Quality-Information Processing, Form GW 0-30
1617 Mail Service Center,Raleigh,INC 27699-1617,Phone :[phone]