HomeMy WebLinkAboutWELL-02-2016-068943.TIF A
�yj .£ WELL ABANDONMENT RECORD
r '�-fa North Carolina Deparnnern of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# •
I.WELLCONTRACTOR 5.' WELL DETAILS:• s
a.Total Dentin /0 V ft Diameter 241 in.
Well Centenor(Individual)Name - b.Water Level(Below Measuring Point): • R.
Mmuring point a_0__ft above Lard surface.
Well Contractor Company Name
STREET ADDRESS 6. CASING: Length• Diameter
• a(lasing Dcyth(if'mown): lr 0 ft _hi
City or Town Sur Zip Code b.Casing Removed: 3 ft in
LL__.)--
Area code-Phone number 7. DISINFECTION: - -
2.WELL INFORMATION: (Amount o165%-75%calcium hypocblorite used) - .
SITE WELL H)N(ifapplieMc)idea_-r7?-IOUs- aL R SEALING MATERIAL:
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STATE WELL PERM TI R(if epplicahle\ Nest Cement Sad Cement
Cement 8 4 ]I/AR•J1 Cement lb.
COUNTY WELL PERMIT 9(f applicable) - Water gel. Water gel.
DWQ or OTHER PERMIT 9(if applicable) katalt '
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WELL USE(Circle applicable sssej Monitoring Residential Baaonim - ID. -
MaincipaVPablic Iadsatrial/Commerrial Agricultunl
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Recovery Injection Irrigation • Type:Slurry_Pdlert_
Othaoi.CUSe) Not in Lice- house on pu61' up4er "'°"` g'
IJ 1
3.WELL LOCATION: I41O )♦dUS�0r1 MI II Rd.
COUNTYZirlpNJYAs QUADRANGLE NAME Type mmerW
NEAREST TOWN: (.oNnnaX'. Amount
(Sncettoad Near,Number.Ccmanby,&tubelir. Let No.,Pam.Zip Code) 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL
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T Slope Valley Ridge SETTING: aU./e t, remictsgre dal are 7jacic
Slope Valley �Y Ridge Other
(Circle appropriate setting)
LATITUDE _'35. 775335 monde.n;za
LONGITUDE__St: 273 dmOl a
10. WELL DIAGRAM:Draw a detailed sketch of the well on the back at this
Latitude/longitude source: Topographic map form showing toad depth,depth and diameter of screens(if any)renainmg
(Location ojwea mss(be shown so a USGS repo asap and in the well,gravel itaavel,intervals of casing perforations,and depths and
orradsed go Wilmot f,.w using OW typo of fill materials and
41 FACILITY.the name of the lane='them the well it laond.Complete 4 amd/b.
DE residential well rtip era:complete 4b,well owner idmaadoa only.) II. DATE WELL ABANDONED 5•..7 a -/6, '
FACILITY ID Rif applicable) '
NAME OF FACILI[Y 1 DO HEREBY CERTIFY THATTHIS WELL WAS ABANDONED IN ACCORDANCE
;Vain sA NCAC 2C.WELL CONSTRUCTION STANDAIUZ AND THATA COPY OF
STREET ADDRESS THIS ACCORD HAS BEEN PROVIDED TO T SWELL OWNER
City of Town Sum zip Code SIGNA'R)RI OF CERTIFIED WELL CONTRACTOR DATE
4d CONTACT PERSON/WELL OWNER:
NAMEnSjn%JVt) 5 +s4sC c - SIGNATURE OF PRIVArlin-E.OWNER ASANDONDiG THE WILL DATE
-(The r"" owner .U ) .m �
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a.eao, reloads!nett STREET ADDRESS 3fee !N �Or De I,aaomax with SM NCAC2CoD.
�Er 6.9 r 3•zq�
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City or Town Sou Zip Cade ZI nkraMC FPE ONABA ND(XpG
I.l. •
(616 ). 951-ts '-
Area code-Phone number
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Sabath a copy to the owner and the original to the Division of Water Qaality within 30 days. Form G •30
Attu:InformatIoa Management,1617 Marl Service Center—Raleigh,NC 27699-1617, Phase No.(919)733-7015 at 56& Rey,yob
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