Haywood_Well Abandonment_20240814

WELL ABANDONMENT RECORD
k c
t North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2194-A
1.WELL CONTRACTOR: 5. WELL DETAILS:
Clyde K Sawyers a.Total Depth Unknown _ft. Diameter:36 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): Unknown ft.
Clyde Sawyers and Son Well Drilling & Pump , Inc. Measuring point is ft.above land surface.
Well Contractor Company Name
80 HII Street 6. CASING: Length Diameter
Street Address
Candler NC 28715 a.Casing Depth(if known): ft. in.
City or Town State Zip Code b.Casing Removed: ft. in.
828 665-2022
Area code Phone number 7. DISINFECTION: 1 gal
2.WELL INFORMATION: (Amount of 65%75%calcium hypochlorite used)
SITE WELL ID# (if applicable)
8. SEALING MATERIAL:
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT #(if applicable)MCM-446WA Water gal. Water gal.
Bentonite
DWQ or OTHER PERMIT #(if applicable)
Bentonite Ib. t "�.,4.• : d.
WELL USE (Check applicable use): Monitoring ✓ Residential
Type:'. Slurry Pellets
Municipal/Public __ Industrial/Commercial Agricultural Water gal. AUG 1 4 2024
Recovery i Injection . Irrigation Other r -7"rr�Srv;'y tom`
Other(list use) Type material Concrete
Amount 3 yds
3.WELL LOCATION:
COUNTYHaywood QUADRANGLE NAME
NEAREST TOWN: Canton 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Pumped Via Concrete Truck
(Street/Road Name..Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC/LAND SETTING:
_! Slope y Valley I_ Flat Ridge_- Other
(Check appropriate setting) 10. WELL DIAGRAM :Draw it detailed sketch of theell on the back of this
form showing total depth,depth and diameter of screens(if any)remaining
LATITUDE 36 0°�'_ "DMS OR 3X.XXXXXXXXmD in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE 75 _ °_' "DIMS OR 7X.XXXXXXXX;PD types of fill materialsised
Latitudellongitude source: OGPS Qropographic map 07/31/2024
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a : THIS REC D
�r BEEN POVIDE D TO TH L OWNER.
(If a residential well,skip 4a:complete 4b,well owner information only.) /
FACILITY ID# (if applicable) G ,_ 4e4 �_ 7/31/24
NAME OF FACILITY SIG URE F CERTIFIED WELL.CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wsonalpbandons his/her residential well
in accordance with 15A NCAC 2C.0113.)
4b.CONTACT PERSON/WELL OWNER: Clyde K Sawyers
NAME PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS
Submit a copy to the owner and the original to: Division of Water Quality-Information Processing, Form GW-30
1617 Mail Service Center, Raleigh,NC 27699-1617,Phone :[phone] Rev.5/10