Rowan_Well Abandonment_20240514

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c :t WELVABANDONMENT ECOR.D
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a �a°. North Carolina Department of Environment and Natural Resources-Division of Water Quality
"�w' ,..! , WELL CONTRACTOR CERTIFICATION#
1,WELL Co . CTOR• , 6. WELL DETAILS: ,
� �i l3ro l,on _ _ 2
l�.leorg a:Total;Depth 12_0 I ft Diameter: In.
Well Contractor(Ind&ldual)Name b.Water Level(Below Measuring Point): 2 C1 ft
`2 o w CL n L)oi1 1. r 1 1 u&C 1 Measuring point is 6 inthe4ft.above land surface.
Well Contractor Company Name
3' 14-0 Sher r ills F0 rcL. 12 6. CASING: Length Diameter
Stree
t Address 6ft, in.
i i.S I [le_ $i 4'i a Casing Depth(if known): •ll(,L.r 1-'
City or Town State Zip Code b.Casing Removed; ft in.
•
( 1704 ) lr 3to q E 961 7. : DISINFECTION: 3 az
Area code Phone number • .
(Amount of 65%75%calcium hypochlorite used)
2:WELL INFORMATION: - 8. SEALING MATERIAL:
SiTE WELL ID# (if applicable)
. Neat Cement - Sand
STATE WELL.PERMIT# (if applicable) Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable)
14 i DI i'3-2 Water gal. Water nal.
Bentonite. ! '
DWQ or OTHER PERMIT#(ifapplicable) ,. �,,.'` a "'
Bentonite 1 a.S'• ,lb. t �r. `'' r,_,L-..•`
WELL USE(Check applicable use)J Monitoring $0Residential 1 aT `� '-�
Type:El Slurrytyiellets
El MunicipallPublic El Industrial/Commercial Cl Agricultural Water / ! gal. MAY 1 !- LUZ4
D Recovery 0 Injection 0 Irrigation Other F_ �c'-r=pa n' L�
° �CJJ 3�
Q Other(list use) Type material
Amount
3.WELL LOCATION:
COUNTY O!Wait QUADRANGLE NAME,
NEAREST TOWN: ,Sal tSb ll Y L. 9. ::EXPLAIN METHOD OF EMPLACEMENT OF.MATERIAL:
i poured ben-orb 4e. p11 5
(StreetlRoad Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC I LAND SETTING:
El Slope D Valley 0i Flat 0 Ridge°Other .
(Check appropriate setting) 10. WELL DIAGRAM:Draw a detailed sketch of theaetl on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
v. LATITUDE 1_ '3L •5 35'"DM5 OR 3X.x X)00000D , In the well,gravel interval,'Intervals of casing perforations,and depths and
LONGITUDE k"3/' S oc " XXt4
DMS OR 7X.)00000 D types of fill materialsised .
Latitude/longitude source: (:)GPS ['Topographic map 11:_DATEINELLAB... ... ED v4' R b— Day
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) I DO HEREBY CERTIFY THAT TMS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT COPY OF
4a.FACILITY.The name(Atha business whore the well is located.Complete 4a 3 THIS RECORD HAS BEEN PBVIDED TO THE WELL OWNER.
(Ira residential well,skip 4a;complete 4b,well owner information only.) 6
FACILITY ID#(if applicable) ✓/G 613/- `aaa
NAM
E OF FACILITY 9 GN ... ECFCE F.iED:WELt.'CON T CTOR' :DATE ,
STREET ADDRESS Ii
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must bean individual wpersonalhebandons hislher residential well
• in 'ante with 15A NCAC 2C.0113.) y-f�—
4b.CONTACT PERSONIWELL OWNER: N liP or (I town .0 i-t�
Ty
NAME C 1 t.I..l i e (YL.Gtt�,.N t c, PRINTED E OF PERSON ABANDONING THE WELL
STREET ADDRESS 143D PLf'& I)t Li,6 rcL Kit
'660604p:1.i, rAc:, as 1,1.1 -
Subm_ it a copy to the owner and tulle original to^Division of Water Quality-.information Processing; Form GW 30
$617 Mail Service Center;Raleigh,NC 27699-1617,.Phone:(919)807=6300. . ` - 1 _1` Rev.5/10
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