Mecklenburg_Well Abandonment_20241001

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i .`. S' WELL ABANDONMENT RE(:O
''''iiFFgt$ * NOrth Carolina Department of Environment and Natural Resources-Diviei of Walter Quality
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11,44 0d~7.:f WELL CONTRACTOR CERTIFICATION# C- .k 3•`- PL
1.WELL CONTRACTOR: 5. WELL DETAILS: ]
T. C.�A% 1 1 Lo v`., a.Total Depth /+��J _+ Diameter: N In.
�Well Cmbactor(Individual)Name Water Level(Below Mee rfIg Point): ��•i; ,tt
. - Iv C• N eel A 1 t�LI ua .1 Ti> OdS e.vfr 5 • Measuring point Is t° __f.above land surface.
W W. Contrector!:ompany ame
StreetPr
Address
A -O 1-NeAt ?\• L. . __ 6. CASING: ? Leant; Diameter
a.Casing Depth(If known 2
C or Town State Zip Cade b.Casing Remove:
r.rea code Phone number 7. DISINFECTION: " /i �7 v`74./, -
2.WELL.tiNFORMATION: • (Amount of 65%75%calcium hypochiollte u
SITE WELL ID* (If appllcablel -� a. SEALING MATERIAL: �-
7
STATE WELL PERMIT# (If applicable)
gent Cement'' ��nt
Cement_ lb. Cement lb.
COUNTY WELL PERMIT #(if applicable) �7 Water gal. Water gal.
DWQ or OTHER PERMIT#(If applicable -�— t3entonite # .N'Z `1. 1:
WELL USE(Check applicable use)i Monitorin9 Residentia_ Bentonite • �� 7 f1 f
l
Li M unto T e L�� /J
IpalA�41bito ❑ IndustrtaUCctrmeroia➢ 1� -'gricukural e:0 Vets
❑ Recovery 0 Injection 0 Irrigation .
Other
Li Other(list use) () ) 2024'
Type material
3.WELL LOCATION: f
N • Amount =f�` % :?'
COUNTY_��� Affr-e-rat/777r-----
ORANGE NAME — — y
NEAREST TOWN: 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(StreetlRnad Name,Number,Community,Subdlvislon,Lot No.,Parcel,Zip Code) !I/� /C�1�G�'2 --:r LJCfjT� �---
TOPOGRAPHC I LANDS NG:
G Slope ❑Valley fat 0 Ridge0 Other
(Check appropriate settiing)��� 10. WELL DIAGRAM :Draw a Mitalied sketch entire)]on the back cif Mk
! LATITUDE 3G w"DM�OR 3x.foopcsocXltmD form showing total depth,depth and diameter of screens any)
in the well,gravel interval,intervals of casing perforations, depths and
LONOITUDE75 DM5 OR Tx.i0000000X r, types of fill materialmsed /
Latitudenongitude spume: PS (]topographic map n
poc-aron Owed,move be•eryoYn on a USOS Popp mop andeftachad to +1. DATE WELL ABAiJDO NED OC
this form ff not using GPS) —
l DO HEREBY CERTIFY THAT THIS WELL.W ABANDONED IN ACCORDANCE
4e.FACILITY-The name of the business where the well is!coated. WITH 15A NCAC 2C,WELL CONSTR CTI N ST
Complete 4a THIS R ANDARDS,AND THATA
(Ifa residential well,skip 4a;complete 4b,we Aar PRVID / E IlOWNER
/ , 7/ ,9?//
FACIUTY ID*Of applicebl �(�- /`
NAME OF FACILITY C 1�,4`f„N„a ATURE FC FEED (INTRACTOR
DA -
L3T DD S ri1•7ODivi L D '
Or Tow State OF PRIVATE WELL.OWNER ABANDONING THE WELL DATE iii, ip Code (The private well owner must be en Udiv du al wjamngbabarulons hlslher m{danyal we;!
4b,CONTACT NMfELLO�W/NER: /j i�nce with 15A CAC2C.013.)
NAME ��//'Jv'.YJN �lftPj�J�Ch i -'•/1/4.1� / /C0*%-.
PRINTED NAME OF PERSON ARANGCHIaG THE WE LL
STREET ADDRESS 1,10 D 1?tit," bLi2j, i .
Submit a copy to the owner and the original to:Division of Water Quality-Information Processing, normOW-30
1617 Mail Service CeContr..","Walsh,NC 27699-1617,Phone:[phone] Rev.
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