HomeMy WebLinkAboutWELL-12-2019-126550.TIF .
tl .
Y pi. + ^ r •WELL' ABANDONMENT•RECORD,
.� - Y•.7, North Carolina Department of Environment and Natural Resources)Division of Water Quality
...fit WELL CONTRACTOR CERTIFICATION#
I.WELL'CIONTRACTOR: -&' WELL DETAILS:
Z.C.`_4a. ;2214a-1. aTotal Depth: ./5.. R Diameter - I4, m, .
•
r Well Contractor(Individual)Name ' b.Water Level(Blow Measuring Point): rat R
a^-3+ve.-f Measuring point is - R above land surface.
Well Contractor Compamj Name 1 I•
STREET ADDRESS +.i 30 L..w.nblOCit- �-a-•� 6. CASING: Length- Diameter
'/c-nP/V •(ALL . Z.&'O • a.Casing DWfa(ifb.on): R iL to.
City or Town State Zip Code' b.Casing Removed e R C) in. '
(53(-= )- 2-,75— CS-Li .
Area code-Phone number 7, DISINFECTION: S t 6- - .
DWELL INFORMATION: (Amount of65%-75Y.calcium hypoctdorite used) ,
SITE WELL ID a(if applicable)• • & SEALING MATERIAL:
t STATE WELL PERMIT 1(if applicable) • •
Neat Cement Sind Cement
COUNTY.WELL PERMITs able • Cement•(.' lb. Cement lb.
( (ifapplicable) Weer O•aS' . get. With Pl. •
DWQ or OTHER PERMIT I(if applicable) pentooiei '
r WELL USE(Circle applicable use): Monitoring Residential
MunitipaWable IadustriaVCommereial Agdeulanl Battonite lb.
Type:Slurry_Pellets_ •
Recovery [ejection Irrigation • -
Other(list use) Water gel.
. Other ``��_'�'T�-e�'3.WELI:IAG11TION: Type material A4tN�' J 74..4
' COUNTY C' - '-- QUADRANGLE NAME (�� .JJ
NEAREST-TOWN: 1)2r%'tP Amount .c-t.a. .
(SwceuRoadNaaw,Number.Cammaairy,Subdivision Lot No.PuveL7ipCode) 9. EXPLAIN METHOD OF EMPLACEMENT OF MA' TERI.w4i+_
TOPOGRAPHIC)LAND SETTING: • I"�,ss..5\b P1;a'- N. "a..A+ (ort4•&L ...• A1/4
Slope Valley Flat Ridge Other I,s,S\`y l;SCI 0,cly/1 yp fa' •'..Sie:r-tsp To....-.
(Circle appropriate setting) �.;... an-\a.-(w%4 coo"c.+rl.• r)_
LATITUDE .Maybe,&pees. ICY
=nit,Ras a,tine
LONGITUDE__ decimal format 10. WELL DIAGRAM:Draw a detailed sketch of the well on the beck of this
Latitude/longitude source: GPS Topographic map form showing total depth,depth and diameter of ssaem Of any)remaining .
(Locaoon afwell murs be slow;on a USGS rape map and in the well,gavel interval,intervals of cuing perfoeatiorn,and depths and
attached to t isjorm Vint using GPS) types of fill materials uad
ha:FACILITY-The tame alibi)bus:.....abate the well is located.Complete(a andeb. Cl.'/ZL.L.)
(If a residential well,skip ea:templets db,well vans information only.) ;II. DATE WELLARAN'DONED Oil I
•
FACILITY m OOP applicable) •
,I WHEREBY CERTIFY.:MAT THIS WELL WAS ABANDONED IN ACCORDANCE
NAME OF FACILITY WITH IIA NCAC 2C.WFLL'CONSTRUCTION STANDARDS,ANDhUT A COPY OF
• THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER_
STREET ADDRESS
City or Town State Zip Code SIGNA OF��D W�NTRACTOR DATE •
alb.CONTACT�PE.RS1ONI WELLL OW�N�ER:: (/�,.... (/
1 NAME 14t4 A• I�CY•v/ l `` � C / SIC ATURE Or PRNATLWLLLOWNER ABANDONING THE �DATL-
i '�.n.(.•W�.-J7.f Sect Velure'wee o,.masut be as aviduil.a nepaiv ebudma hinbaresidt:dal;ai
STREETADDRESS 21.7b '.yn maoeadaoeawia11ANCACZC.dll1.)
Guava.✓+' N.SC. 12234 .Ee-Seth .ta-.Qsa.<Ie l i[..
3 City or Town Sare Zip Code •PRINTED NAME OF PERSON ABANDONING THE WELL
F
(33G )_ ear Grit
Area code-Phone number
Submit a copy to the owner and the original to the Division of Water Quality within 70 days. • Font,OW-30 .
'Ann:Information Mivagemen41617 Mail Senile Center-Raleigh,NC 27699-1617,.Phone Nat-(919)733-701S at56& Rev.5/06.
i
t
e
F
t
L
5 f
•
•
•
.. `4� �� - ' ter .
GQ.,... I
(. Al
�'� .. •
•
•
_. ^ - . .