Guilford_Well Abandonment_20240710

.ter-t t WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL CONTRACTOR/ / 5. WELL DETAILS:
Sy,,, a Total Depth:
_I2� _R Diameter. in-
W..{ell Contractor(Individual)Name _ b.Water Level(Below Measuring Point): ft_
J p Z n �h ��/) `�H7 . � L,)e/� C 49' L A4. Measuring point is� �r ft.above land surface:.
Well Contractor Compfiny Name
STREET ADDRESS _ r> _ Ly 3 y71 a'k u e � � 6. CASING: Length Diameter
a.Casio th(ifknown): ft. in.
City btTown State Zip Code b.Casing Removed- 3 ft. in.
Area code-Phone member 7. DISINFECTION:
2.WELL INFORMATION: (Amount of 65w/75%ealeitun hypochlorite used)
SITE WELL ID#(if applicable) IL SEALING MATERIAL:
STATE WELL PERMIT#(ifappbcable) Neat Sand Cement
Cement lb. Cement lb.
COUNTY WELL PERMIT#(ifapplicable)•2 y y's ir/PNL'i b L^�G} Water gal. Water IpL.
DWQ or OTHER PERMIT#(if applicable) Bentonite -. -••�
��L`.�1.:� if
WELL USE(Check applicable use): ❑ Monitoring )z Residential Bentonite lb_ 1 j E E'
❑ Municipal/Public ❑ Industnal/Cotrmercial El Agricultural Type:[I Slurry ❑Pellets iUL 1 0 2024
Water gal.
❑ Recovery ❑ Injection ❑ Irrigation lfifd:R+6��41 Arm"�y;e'e Utz
Other D*(:W9C4
❑Other(list use) l L -(' /r�
Type material C z m a„7 0 T
3.WELL LOCATION: AmountL
COUNTY;/_QUADRANGLE NAME
NEAREST TOWN: _S- S do-I C 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
�,3 1/to -✓ •tic
(Street/Road Name,Number.Cornnnunity,Subdivision.Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SEI-TING: �� r*t c � ►�a.c. !l^
❑Slope ❑valley ❑Ridge❑other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
LATMME Z�C / May be indel7ees• form showing total dearth,depth and diameter of screens(if any)remaining
J atinutes,seconds,or in a
9 deeirnal forrrnt in the well,gravel interval,interv:rLs of casing sing perforations,and depths and
LONGITTJDE (l�C i_ types of fill materials used.
LatitudcAougitude source �PS ❑Topographic map _
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED
attached to thisform if not using GPS.)
1 DO HEREBY CERTIFY THAT THIS WI':U.WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The a==of the business where the well is locatcd.Complete 4a and4b- WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS.AND THAT X COPY OF
(Ifa residential well,skip 4a;complete 4b.well owner information only.) THIS RECORD HAS BEEN PROVIDED 1-0 THE WELL OWNER
FACILITY ID#(if applicable) —�
NAME OF FACII=
SiG�ATURE OF CER FI� VELL CONTRACTOR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner[twat be an individual who personals abandons histlter residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with ISA NCAC 2C.0111)
NAME ed r k �L at L✓ S®h.
n
STREET ADDRESS I}19�3 1 i m h L %h c J�� PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.[phone] east 568. Rev.5/06