Brunswick_Well Abandonment_20240814

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality -
�-- � WELL CONTRACTOR CERTIFICATION#
I.WELL CONTRACTOR: 5. WELL DETAILS:
(
I r`e- a.Total Depth:'2 S ft. Diamcim_J"
Well Con/tr�tac/w(Individual)pNI �y 1 l /�. n' n(� b.Water Level(Below Mcasurmg Point): 8.
,E FQ q . we l L 1/t l 1 1�G I o K t (�4/J Measuring point is ft.above land surface.
Well Co tuna 0 1
STREET ADDRESS 4,45-7`t— 5--'11 f 6. CASING: Length Diameter
J( l on l y 1 0+ K)-l_� 2 5T 2-Of a.Casing Depth(if known): ft. in.
City or Town State Zip Code
b.Casing Removed: ft in.
Area code-Phone number 7. DISINFECTION
2.WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Ne*t Cement Sand Cement
COUNTY WELL PERMIT#(if applicable Cement lb. Cement lb.) Water gal. Water gal.
DWQ or OTHER PERMIT#(if applicabk) 84tonite ,
WELL USE(Check applicable use): ❑ Monitoring Residential Bentonite AMP-9Q
❑Municipal/Public ❑ Industrial/Commercial ❑ Agricultural Type:❑Slurry oellets
❑ Recovery [I Injection [I Irrigation Water Z�` gal.
❑Other(list use) Other
Type material
3.WELL LOCATION:
Amdunt
COUNTY i i QUADRANO E NAME
NEAREST TOWN: 4e
2 D M19 ecn f,a 9. EXPLAIN METH D OF lWPLACEMENT OF MA R14L:
(Saeeb%oad Name,Number,Comm nay,Subdivision,Lot No.,Parcel,Zip Code) r
TOPOGRAPHIC/LAND SETTING:
[]Slope []valley Flat ❑Ridge❑Other
(Check appropriate setting)
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
May be in degrees, form showin total
LATITUDE _ _ rnutes,sew,or in a 8 depth depth and diameter of screens(if any)remaining
decimal format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE__ types of fill materials toed.
Latitnddlongitade source ❑GPS ❑Topographie map
(Location o)riwJl must be shown on a USGS ropo map and
11. DATE WELL ABANDONED �� /
attached to thisform if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4%.FACILITY;The now of the b sinew where the well is located.Complete 4a and4b. WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(Ifa residential wall,skip 4a.compbtc 4b,well owner bdbmration only.) THIS RECORD BEEN ROVID TO TH E WELL WNER.
FACILITY ID#(irapplicabk) t
NAME OF FACILITY
SIGNATU OF CE ED CO CTDR DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner most be an individuafwho pcgowilyabandons his/her residential well
4b.CONTACT PERS /W�EnL,L++OWNER:
/� �,( in accordan a sy SA NCAC 2C.0113.)
NAME 1V 1 I e��l W a`Key—lilCte i
t PRINTED NAME OF PERSON N G THE WELL
STREET� ADDRESS. n
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW 30
Attn:Information Maaagement,1617 Mail Service Centex—Raleigh,NC 27699-1617, Phone No.[phone] est 568. Rev.5/06

s
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality -
2Zq —A
--�� WELL CONTRACTOR CERTIFICATION#_
1.WELL CONTRACTOR: 5. •WELL DETAILS: r
a.Total Depth: 3T _ft. Diameter:_in.
Well Contractor(Indivi ual)Name b.Water Level(Below Measuring Point):_Izo_ft.
',-)e- - offil, Measuring point is—A_fL above land surface.
Well on .panj N
STREET ADDRESS _ .J (,l� 1 ( I 6. CASING: Length Diameter
C-06 t e- kQJy- ne- �3.L a99 31 a.Casing Depth(ifknown): R, in,
City or Town State Zip Code b.Casing Removed: ft. in.
c 4/0)- Z3l (( 9 Lj
Area code-Phone number 7. DISINFECTION -Ft
2.WELL INFORMATION: (Amount of 65e/,75%calcium hypochlorite used)
SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable Cement lb. Cement lb.) Water
gal. Water - gal.
DWQ or OTHER PERMIT#(if applicable) Beh tonite ,
WELL USE(Check applicable use): ❑ Monitoring Residential Bentonite' lb• •4 V,
❑Municipal/Public ❑ Imiastrial/Commereial ❑ Agrimitural Type:❑Slurry Pellets
❑ Recovery ❑ Injection ❑ Irrigation Water o�Q gal•
Other
[IOther(list use)
Type material
3.WELL LOCATION: Arndunt
COUNTY[ UADRANGLE AME
NEAREST TOWN: 9. EXPL N METH OF E LA WENT OF MATER L:
.�$ SMY' QR
(Suret/Road Name,Number,Commtmity,Subdivision,Lot No.,Parcel,Zip Code) `
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑valley )(Flat ❑Ridge❑Other
(Cheek appropriate setting)
10. WELL DIAGRAM:Draw a dotailed sketch of the well on the back of this
LATITUDE May be at demos' form showing total depth,depth and diameter of screens(if any)remaining
ddcet�, t g
or in a in the well, avel interval,intervals of casing perforations,and depths and
LONGITUDE types of ft11 materials used.
Latitude/longitude source: ❑GPS ❑Topographic map(Location of xv.A must be shown ore a USGS topo map and 11. DATE WELL ABANDONED
adaclred to thisform ifnot using CPS.) 1 DO HEREBY CERTIFY THAT THIS WELL WAS AISAN 2V1;;M ACCORDANCE
4a.FACILITY;The name of the business where the well is located.Coal eft 2a zad4b. V6 M 115A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND I RAT n Coi-f OF
(Ifa residential well,skip 4a;complete 4b,well owner information only_) THIS RECORD S B N PROVIDED TO T't?E Wr.t_' O1.11NLl.
FACILITY ID#(ilrapplicable) +
NAME OF FACILITY C �4
---- SIGNATtJok 6F CERTIFIED VS' L CONTRACTOR _ DATE
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
Mle private well owner mast Sear,iadividua(who p rsonal yabandons his,t residential wen
4b.CONTA E,RS 11 ii c,ii v'n i� n in accords w h 15A NCAC 2C.0113.1 Q
NAME — ����
(•dL PRINTED NAME OF P t RSON ABANDONING THE WELL
STREET ADDRESS.
Submit a copy: ..rcr a -'Me Q.rprwl' tuc DIVE.rii di ii nicr Quauiy wnuiu 30,days. Form OW-30
Attn:Information ManaP_"emonl 1617 Mpt-Service Cuter_Aft i ti rot 1-16on t6+-r ohs-- .,- .+....•. -
- - - =: , -- - i--•,•�.�7V41 W8tav0. Rev.5i06