Robeson_Well Abandonment_20240910

- ty WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
— WELL CONTRACTOR CERTIFICATION# i
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1.WELL CONTRACTOR: 5. WELL DETAILS:
LLOYD MARES a.Total Depth: 44 f' ft. Diameter:1 11/4 in.
Well Contractor(Individual)Name b.Water Level(Below Measuring Point): 13 ft.
REGISTER WELL CO, INC. Measuring point is 1.5 ft.above land surface.
Well Contractor Company Name
STREET ADDRESS 721 W CHARITY ROAD 6. CASING: {! Length Diameter
ROSE HILL NC 2845 a.Casing Depth(if known): l ONKND ft, 1 1/4 in.
City or Town State Zip Code b.Casing Removed: ; Q ft. in.
(910 )- 289-3175
Area code-Phone number 7. DISINFECTION: 6 OZ HTH
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2.WELL INFORMATION: (Amount of 650/&-75%calcium hypochlorite used)
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SITE WELL ID#(if applicable) 8. SEALING MATERIAL:
STATE WELL PERMIT#(if applicable) Neat Cement Sand Cement
COUNTY WELL PERMIT#(if applicable)415053-1 Cement lb. Cement lb.Water gal. Water gal.
DW Q or OTHER PERMIT#(if applicable) Bentonite
WELL USE(Check applicable use): ElMonitoring Z Residential Bentonite lb. i—L (z—i:f
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❑ MunicipaUPublic ❑ Industrial/Commercial ❑ Agricultural Type:❑Slurry ❑Pellets ..
Water Igal. SEP 1 0 e�24
❑ Recovery ❑ Injection, ❑ Irrigation
Other U
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❑Other(list use) �^r�::
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'Type materials
3.WELL LOCATION: Amount
COUNTYROBESON QUADRANGLE NAME
NEAREST TOWN:, LUMBERTON
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
143 CRABTREE LANE POUR SLOWLY
(Street/Road Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHIC/LAND SETTING:
❑Slope ❑Valley Z 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 showingtotal depth,depth and diameter of screens if an remaining
LATITUDE 34.613780 minutes,seconds,or in a p p ( y) g
-78.975466 decimal format in the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE __ types of fill materials used.
Latitudellongitude source: Z GPS [:]Topographic map
(Location of well must be shown on a USGS topo map and 11. DATE WELL ABANDONED 8/13/24
attached to this form if not using GPS.)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a.FACILITY-The name ofthe business where the well is located.Complete 4a and4b. WITH 15ANCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
(Ifa residential well,skip 4a;complete 4b,well owner information only.) THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
FACILITY ID#(if applicable)
Z—Z-Oyt) 7 W
NAME OF FACILITY '
SIGNATU OF CERTIFIED WELL CONTRACTOR DATE
e 1.
STREET ADDRESS
City or Town State Zip Code SIGNATURE OF PRINitTE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual who personally abandons his/her residential well
4b.CONTACT PERSON/WELL OWNER: in accordance with 15A NCAC 2C.0113.).
NAME BRANDON JACOBS o u i 'T-Uw S
STREET ADDRESS 147 CRABTREE LANE LUMBER-TO PRBVTEDNAM OF PERSON ABANDONING THE WELL
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Submit a copy to the owner and the original to the Division of Water Quality within 30 days. I Form GW-30
Attn:Information Management,1617 Mail Service Center—Raleigh,NC 27699-1617, Phone No.(919)733-7 015 ex't 568. Rev.5106
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