Catawba_Well Abandonment_20240610

F ' `� a WELL ABANDON WENT RECORD
. r !1 „. North Carolina Department of Environment and Natural Resources-Division of Water Quality
• WELL CONTRACTOR CERTIFICATION # a. �' ` .if '
1 CONTRACTO I
5. WELL DETAILS: .Q Al l
Va.1'otal Depth:_ ft Die:neter., �!n. I
• ..„Contractor(Individual)Nacre / b.Water Level(Below Me •unn Point):_ __- `t
• J,� ` , p,,3�t- +C _ � _10
Measuring point is' ft.above land surface.
wall .otttractor omprnp-Nanc
STREET 'ADDRESS R/6R 4. , U8 6. CASING: 1-ength Diameter
w C Vo ga a.Casing Depth(if known) R. 2 Q in.
Oily or Town State Zip Code b.Casing Removed: _ft. n
K' 3�f
p_y_
-PIrn�.dmber �` • 7. DIS!NFECTio'_�� 4'6,` i e
2.WELL INFORMATION: (Amount of 65%75°/a calcium hypocblorite used)•
a`•'
SITE WELL ID l(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT•#(if applicable)____���� I` Neat('morn' Saint Cement
2_V,-�� Water __ b. Cement
COUNTY WELL PERMIT p(if applicable 7 _ 'Water_ __gal. Water -�;a!
DWQ or OTHER PERMITS(if applicable) Bentonite ...
•
WELL USE(Check applicable use): ❑ Monitoring :Ti s dal { Bentonite ib. a �'�' ;
❑ Municipal/Public ❑.IndustrlaVCommerclal 0 Agricultural • Type:❑Slurry DPellets JUN ! Ci ,
Weter gal.
❑ Recovery ❑ Injection 0 Irrigation bltf�ftttt>yr�;4i�
Other rct•' e u'g
❑Other(list use) O©C ,r })
Type mate:i t►/�+� (!
3.WELL LU��'ATI Amount
COUNT l�,/� ADRgNCLE NAME __.___
NEAREST TOWN:
J 1 Ai4 O � 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
ue
(StreerRoad Name,Number.Community,Subdivision, of No.Parce'.,+'►c — --_
TOPOGRAPHIC/LAND SETT�IJG: -- --.•— -----
0 Slope ❑Valley at ❑Ridge❑Other -- — --
(Check appropriate setting) I
4 �� ---- 1U. WELL DIAGRAM:Dr£w a detailed sk.tch of the well on the back of this
�. May be in degrees, form showing total depth,depth and diameter of screens(if any)remaining
l LAT1Tli minutes,second_,or in a
/G +f :coal formatin the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE$� .f r types of fill materials used.
Latitude/longitude source: 4Eltp< ❑Topographic map • +'�a ��
(Location of well inner be shoo non a USGS topo'nap and II. DATE WELL ABANDONED. `
attached to this form ij not using GPS)
. 1 DO HERESY CERTIFY THAT Ti•IIS WELL WAS ABANDONED IN ACCORDANCE
an.FACILITY-Ti*name of the business where the well is located.Complete 4a and4b. WITH ISA NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(Ife residential well skip 4a.complete 4b,well owner information only.) THIS RECORD HAS sriEN PROVIDED TO THE WE_L OWNER.
FACILITY[D#(if applicable) i • r�� ��
NAME OF FACILITY ' C-� -
SI 'NATURE ER1'IFIL'D WEL CONTR4Cl' UA lli
STREET ADDRESS ......
City or Town ' State' Zip Coda •SIGNATURE OP PRIVATE WELL OWNER ABANDONING THE WELL DATE
(Tile pnvate well owner must be an individual who personally abandons his/her residential well .�
4b.CONTA PERSON/WELL OWNER: `, in c with iSA NCAC 2C.0113)
NAME a ~ — ,oci ' O! , d f7 PR NTEDNAME PERSFBAND ,'IN' T EWELL
STREET ADDRESS
I
Submit a copy to the ow n :and the original to the Division of Water Quality within 30 days. Form OW-30
Ann:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] ext 568. Rev.5106

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