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HomeMy WebLinkAboutWELL-05-2021-150456.TIF I c4r) WELL ABANDONMENT RECORD North Carolina Department of Environment and Natural Resources-Division of Water Quality `"` WELL CONTRACTOR CERTIFICATION# 1.WELL CONTRACTOR: 6 WELL DETAILS: a Total Depth: 3 7 ft Diameter. in Well Contractor(Individual)Name ` b.Water Level(Blow Measuring -��J R Measuring point is () ft above Iand surface. Well Contractor Company N / // STREET ADDRESS 6. CASLN'G: Leriggthh Diaar(nteter 07 a.Casing Depth(if known): 3.._ ft. L,1 in. City or Town State Zip cm, b.Casing Removed: © ft. _ in. Area code-Phone number 7. DISINFECTION: ' 1 ' b)e' GI i WELL L'vPORMATION: (Amount of 65%-75% cium hypochlorite used) SITE WELL ID I(if applicable] 70 $ky 1,is r_ MATERIAL: • STATE WELL PERMIT N(if applicable) I vest Cement $cad Cement wEe1,-6S�n?1-(9 .5(D C _/,�y lb. Cement lb. COUNTY WELL PERMIT r(if applicable) Water G gal. Water Bal. DWQ or OTHER PERMIT Y(if applicable) Bentonite WELL USE(Circle applicable usek Maaitering Raider MunicipaVPablic Ldm ra trisVComerdal Agrkaharal Bertotti[e lb. Recovery Injection irrigation Type:Slurry_Pellets_ Other(list use) Water gal. Olber 3,WELL LOCATION: COUNTY(iij4441 QUADRAN LE NAME{ Type material NEAREST TOWN: C.r r. ,r ! q" Amotrit tk .S 7f''-L r (Sawa/Rood Name,Number,Ccenrou a ty,Subdivision,let No.Parcel,Zip Code) 9. E LAIN 1 OD F CEMENT OF MATERIAL: To" ' 'BBC/LANDSla11NG, / 40 Valley Flue Ridge Other �(lf�/ Lf/ f C �r't G -From appropriate setting) 111 {� G'T t,�T t� t.1/-e r LATITUDE May in degrees, — — mimes seconds,ere to• LONGITUDE decimal format I0. WELL DIAGRAM:Draw a detailed sketch of the well on the back of this Latitude/longitude source: GPS Topographic map form showing total depth,depth and diameter of screens(if arty)remaining m ssoni d wwrhtr onset t ,shown on a USGS lopes snap and in the well,gravel interval,intervals of casing perforations,and depths and 1 (1 toms GPS.) types of fill materials used ea.FACILITY.The muse of the brain=where the well is located.Complete 4 asdeb. r f / • (If a residential welt,drip 4;eotttplete 4b,well owns m inforea M' oe only.) 11. DATE WELL ABDONED <Si�'S r/ �v)�2 FACILITY ID k(if applicable) NAME OF FACILITY I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE WITH I SA NCAC 2C.WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF STREET ADDRESS THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. City or Town State Zip Code SIGNATURE OF CERTIFIED WELL CONTRACTOR 4b.COhTA P ON/WELL OWNER: / DATE NAME IU fyi3Of fk � lA ( rl�rt°nG ���/��� SICNA OF PR/VA •WELL OWNER ABANDONING THE LL DATE STREET DRESS ] (The privets well meow mat be a odiviead who l'l, k��^!5 �r in' 'no'�p ISA NCAC 2C.0I 13.) rO` Ily.b..jd~m.bi»s"reed°°oal wail /r,.t eA ( 3-4fCp -)e.afth rnoC O J/ cjJ ), City or Town Sane Zip Code PRINTED ►NAME OF RSON ABANDONING THE WELL. • ( 't ' )- 2oO`0L 11 • Area code-Phone number Sabah a copy to the owner red the orisiaal to tie Division of Water Quality wit►i■30 days. Attu:latormadon Management,1617 Mail Service Center-Raleigh,NC 27699-1617, Phone No.(919)733-T015 eat 561t. Form G 06 Rev.5/06