Cleveland_Well Abandonment_20240710

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t WELL ABANDONMENT RECORD
• North Carolina Department of Environment and Natural Resou cei-Divi ionof Wateir Quality
WELL CONTRACTOR CERTIFICATION 4 ,
t,VVEL NTRACTOR: , 5. WELL DETAIL1$: t
DR` _.• s 1 5 I a Total Depth: (0 O ft. Diameter: in
r 1 Contractor(I rviduaq N ne �!'� b Water Level(Below Me a ng Point) R.
j� ��� M.easuring Levelpoint is l 1 _4 above land surface.
itercbr: let o.r y N a U
sa 6. CASING: Len h Diameter
LET ADDRESS
EA .! 1 i A L e C. �7V /6 i a.Casing Depth(if known): _ft in. I
ity o 'ow ft,State Zip Code b.Casing Removed: t A in.
y� i ' 3 y 7. DISINFECTION: t �(v G • I
Ares code-Phone number
(Amount of 659675%calcium h'pochlorite used)
2,WELL!INFORMATION:
SITE WELL ID#(:f applicable)_ _ _— S. SEALING MATERIAL: .
•
�t Cement •Cvi►d Crm►nt
STATE WELL PERMIT#(if applicable)—
�^ ^ }/}/} //�Q' Cement _lb. Cement lb.
COUNTY WELL PERMIT#(i app t abiel7 I/!/1 7 O eater _gal Water gal
t--
DWQ or OTHER PERMIT#(if appiicable)_�•_ _. — etoahe
c esidentlal Bentonite lb
WELL USE(Chock applicable use): ❑ •Monitoring
Muni 0 Industrial/Commercial ❑ Agricultural Type:❑Slurry ❑Pellets
Water gal.
❑ Recovery ❑ Injection 0 Irrigation ::nateria
❑Other(list use) i� � ea/V CA ,
3.WELL L TIOyyN: Amount
COUNTY 4 Y it,?..! a•A• GL-c NAME ^_.
N•'A EST TCWN: --- l 9. EXPLAIN METHOD OF EM LACEM_ENT OF MATERIAL:
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code) II 1 0 Ct t Z
TOPOGRAPHIC/LAND SE G: 4
"--
❑Slope 0 Valley lot ❑Ridge❑Other_ Ity(,5:14-4:r ,1''"-" r L tt•
(Check appropriate setting) o'A c.SC4
1t WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
��' / May be in degrc«, I form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE c' m citrtl seconds,yr in 1 in the well,gravel interval,intervals of casing perforations,and depths and 1
zit,
L 4 9 I decimal format
LONGITUDE J types of fill materials used.
Latitude/long Itude source: GPS 0 Topographic map .
r
(Location of well must be shown on a USGS topo map and IL DATE WELL ABANDONED 6A • 041 .
1
' attached to this form if not using GPS.) 1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name of the business when the well is located.Complete as and-lb. t+ti t15 RE O:sAHAS BEEV C 2C.WELL P OV CONSTRUCTION
IDED TO ON STANDARDS,
NDARD ,AND THAT A COPY OF
i (it•a residential well•skip 4a,complete 4b,well owner information only) • t
FACILITY ID#(if appli I /c .
NAME OF FACILITY • f_. J SI NATURE. ,RTIFIED vv'ELI. 'T CTOR DATE
STRE f A ESS /I11' G
Cit ` SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
State :p aab so hillier residential well
City or Town (The private well owner must be an indnidual who;�ctso*.a'.).t;
*seem l ith I5A NCAC 0 13.
Ab.CONTAC PE SON/WE L OWNER' T ' r
NAME /� P NTED?IAR1E Oy
RSON ABAVD .'I�'ri i'HE WELL
STREET DDRFSS_ 0 w 2 I
C !.
Form GW-30
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Rev5/06
Attn:Information Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.(919)733-:015 ext SOS.

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