Moore_Well Abandonment_20241025 (2)

AK 'G
WELL ABANDONMENT RECORD
Y Y= North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION#
1.WELL
c-t'
LL CONTRACTOR: 5. WELL DETAILS:
,. J1 /-3, &1,4/d1, a_Total Depth:ft Diameter: in.
Well Contractor(Wividua))Name b.Water Level(Below Measuring Point): /Z fL
L1811..t 414-A�c �ca/ec�i .f Measuring point is f ft above land surface.
Well Contractor Company Name U.�2Y -
STREET ADDRESS i�z� /7�/ Z3 6. CASING: Length Diameter
Ct��S f - /V_i m z7 3.7.E'
a Casing Depth(if known): ft T in.
City or Town State Zip Code r�
b.Casing Removed: j _R 5F in-
�o -1!�q 7 9--30-3
Area code-Phone number 7. DISINFECTION:
?-WELL INFORMATION: (Amount of 65%75%calcium hypochlonite used)
SITE WELL ID#(if applicable) & SEALING MATERIAL:
STATE WELL PERMIT#(if applicable Neat Ceme>.t Sant Cement
COUNTY WELL PERMIT#(if applicable) Cement ----—1b.' Cement--'Ib-
Water �'
gal. Water gal.
�P a rat!
DWQ or OTHER PERMIT#(if applicable) Bentonite �(
WELL USE(Check Applicable Box):0 Monitoring Residential c�/C!
0 Municipal/Public ❑Industra iU ❑Ci mmerval Agricultural Bentonte��lb. Qj 5 0 r T 2 i` 2 G L 4
C Recovery ❑Injection C Irrigation Type:Slurry Pellets
❑Other(list use) Water i gal. J
Other
3.WELL LOCATION: Type material
COUNTY rn QUADRANGLE NAME Amount .SA K✓i z (JL
NEAREST TOWN- T-C'N.7 /Ue Z rT 3 rf�i
Ate-ei A& z
(Stfect/Road Name N,wber,Community,Subdivision,Lot No-Pnmrl,Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TOPOGRAPIEC/LAND SETTING: lly i a
OSlope ❑Valley OFlat ORidge 0 Other � yR�ft"C !u �y 0,-"(Check appropriate box)
37 r �7 May d�
IT LATUDE - `1 L I G�sa / ,minutes,seconds,or in a
LONGTTUDE r' -3 t � r t d�COS
�—� 10. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this
Latitude/longitude source: atQPS ❑Topographic map form showing total depth,depth and diameter of screens(if any)remaining
(Location gfwe//instep be drown on a USGStwo map and in the well,gravel i tuval,intervals ofcasing perforations,and depths and
attoebad to this force if not using GPS)
types of fill materials used-
4a.FACHdTY-The now of the beaness where the well is locad Campteoe 4a and4b. 11. DATE WELL ABANDONED
(Ifa fiat well,skip 4a;complete 4b,well owner information only.)
FACTLTfY ID#(if applicable) J-aft t t /v e w 1 DO FWRFBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
^. � - WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
NAME OF FACILITY T9*tArL S ti ' THIS HAS BEEN PROVIDED TO THE WELL OWNER
STREET ADDRESS fill./B�t ���• '- e Z
L T 7 SIGNATURE OF CP IFEE.D WELL CONTRACTOR DATE
City or Town State Zip Code
4b.CONTACT PERSONIWELL OWNER
�-[ifG X✓�t i4 �/ — SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
NAME
1 (Ile private well owner mat be an indMiltiai who Damalty abandons his&w residential well
in accordance with 15A NCAC 2C.0113.)
STREET ADDRESS yAt/l%e�o 4A(
PRINTED NAME OFPERSON ABANDONING THE WELL
city or Town State Zip Code
C - 61 tips z
sex code-Phone number
Submit a copy to the owner and the original to the Division of Water Quality within 30 days Form GW-30
Attn:lnformation Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.[phone] ext 5W Rev.4/06