HomeMy WebLinkAboutWELL-06-2018-101805.TIF r'Y^nY'�f-
"" WELL ABANDONMENT RECORD
`'`; North Carolina D of',.or._,
-J Department Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION N
I.WELL CONTRACTOR: & WELL DETAILS:
Well Contractor(Individual)Name a.Taal Depth: f( ft. Diameter m
b.Water Level(Below Measuring Point): ft,
Measuaingpoint is ft.above land surface.
Well Contractor Company Name
STREET ADDRESS 6.. CASING: Length Diameter
City or Town State Zi Code a Casing Depth(if known): t t $ Li in
p B.Casing Removed: Z fL z y in.
Area code•Phone number 1. DISINFECTION:
2.WELL INFORMATION: (Amount of 65%-75%calcium hypochleritc used) - '
SITE WELL ID#(if applicable) S. SEALING MATERIAL:
STATE WELL PERMIT N(if sop!r at+le) Nett Cement Sand Cement
COUNTY WELL PERMIT 8(if applicable) Cement lb. Cement lb.
Watcr gal. Water
. gal.
DWO or OTHER PERMIT al(if applicable) Bentooite
WELL USE(Circle applicable use) Monitoring �esideou
MuoieipaUPnbfc Lada<strtalfCommereiat i grteuriural Type:Bent Slimy_
lb.
Recovery Injection Irrigation - Type:Slimy_Pellets_
Other(list use) Water gel.
Other
3.WELL LOCATION:
COUNTY 1,41A W ikR" QUADRANGLE NAME Type mist
NEAREST TOWN: S.b G ft(1(5 ford Amount -
•
(Sacs:/Road Name,Numla,Community,SAb&rierem,Lot No.,Parcel.Zip Code) A EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
••• RAMC/LAND SE"IT1NG: C'ow -Pt g C1+1+ G App E us T4.
4 1Z, valley Flet Ridge Other (a rr 6. ad AiCr ' E--
(Circle appropriate setting)
L ATTITIDE 3$' n 5.1 i� May be in degrees.
minutes.seconds,aria
I ONGITUDi QOa}•$n fY/$" decimal fob
10. WELL DIAGRAM:Draws detailed sketch of the well on the back of this
Latitude/longitude source: GPS Topographic map form showing total depth,depth and diameter of acirens(if any)remaining
(location of wefj meat be.chaww on a US>JSropo snap and in the welt,gravel interval,intervals of casing perforations,and depths and
wadted to r/rtsfon n f not eating GPS.) types of fell materials used.
{a.FACILITY-The name of the Naito' sa where the well is belted.Complete 4a an dab.(Ira residential well,dip ilk;complete 4b.WIC mummuminformation only.) I I. DATE WELL ARANDONED ///
-- g 0/g
FACILITY ID*Of applicable) -
NAME OF FACILITY I DO HEREBY CERTIFY THAT TIS WEIL WAS ABANDONED IN ACCORDANCE
virtu 15A NCAC 2C,WELL CONSTRUCTION STANDARDS AND THAT A COPY OP
•
STREET ADDRESSTHIS RECORD HAS BEEN PROVIDED TO THE WELL OWt Es
City or Town State Zip Code SJGNATURE OP C£R'1TJrWD WELL CONTRACTOR
4b,CONTACT PERSON/WELL OWNER: DATE
rtAadE I`�raNdt1 S;s{Es • Si 5.25-22—
Si(+NATURE Or ATE-WELL OWNER ARAN i a t. THE WELL DATE
STREET ADDRESS $!�'/ r £ - (The private well Or'
bean indi.�dael who pc-v.03v abandons his/her
residential wsll
in accerdency wine ISA NCAC2C 0II3.)
_I-s Err;is l'o�� 111 C. 046,73
I
City or Town State Zip Code S,�
BUNN 1 OP PERSONABANDONhNO THE WELL
( 7O(/ )- ii67-77S7 -
-
Area code-Phone number
Sabah a copy to the owner and the original to the Division of Water
Quality within )0
Attn:Information Management, dal!Service Center—Raleigh,NC 6 1�Phone No.(919)T,33-70IS est 568, FForm30
Rev-5106
Coke
9' clean fill
2' casing removed to below ground