HomeMy WebLinkAboutWELL-01-2023-187705.TIF I ' J
WELL AD, UONTRECQD I cJo o)
Narth Calina Dapemont of ErlroruneLtt and ivahal t ResorrCes-D(vlslon of Water Quality ,�
\''"4"".w^' WEt,1l,CONTRACTOR CERTIFICATION# 11\\C1,- 13, '` Y
1.WELL COS�NTTRACTOR: 6. WELL DETAILS:
" V�+i C�Ai;. ��el\ tQ , a.Tolel U (�
Well Contractor(individual)Name Depth 1 L ft. altimeter, ZI!
`� 1 b.Water Leval(Below MWae king Paint);,�2 I
r" ^ �ri C.• 1,e�A 1 1?1 rl TM Xvt S-ttrvl eve S, Meaeurfng point la ft.above land surface.
We Contractor Company
^erne
PCP
Sire T" 'z)v.:�",e,A� �A, L NI, 8. CASINO: Length Diameter
ç
A a.Ceaing Depth(I{[mown): ft • !n.
yorT���.i ,l V, 5 NI C_, • , ,a2,tawn ( State Zip Coda b.Casing Removed: t ft. �..._(r+
Area code Phone number7. DISINFECTION: i)y4(�t,C{ �' 4p„r( ,r k C'/.,'1,�"'..^"f�
2.WELL INFORMATION: (Amount of a6%75%calcium hypochlorite used)
SITE WELL ID#(If applicable) a. SEALING MATERIAL;
STATE WELL PERMIT# (If applicable) /----- Noatlettmitt ganr➢Cene µ
Cement �-
/ 1b.-- Ceman Ab,
COUNTY WELL PERMIT Of(If appRcaBl®?lf�Wi� 1Yf //✓ Water - gal. W ��"`r"� af.
DMorOTHER PERMIT#(tappllaable) — pdg R>te
WELL USE(Check epplfcabte use}] MonitoringIdentlal Bentonite tee lb. i.b. -1--
L MunIcipaliPublla 2 InduslrlatIConuneralal Li fi+3rtoultural eTyprCl9iurry allele
Waatter °sal,
0 Fivae,aty 0 Injection LI Irrigation ✓_
Ll Other(list use) ¢)tl1er Yam=
Type material
S.WELL LOCATION, Amount
COUNTY(-7747141/t UAORA'NRtE 11.01E l •
1
tt
NEAREST TOWN: A-e_A• '/
// - /-e,04..4 9. EXKAI ETHOD OF EMPLACEMENT OF MATERI
(8inecllFtoed Hama,Mintier.Conmunity,Aubdivlalon u` 0- !4�"ems•+8' i"Lit No.,Parool.rp Costa) - �'� L C 3�
TOPOGRAPHC if LAND SETTItIO:
D Slope 0 Valley 0 Rat Other fl/
(Check appropriate salting) 1a. 11I/CLL DIAGRAM:Draw a detailed°ketch of thrall on the
bad rtsformshwin total depth,depth and diameter otsoraens Ratty)remaining
ningATDE r3 a 54/ � " MS OR aXXRXX ]D In the wall,gravel Interval,Intervals of casing perforations,and depths end
LONGITUDE , 'u0"111(7 MS OR 7x.}t5Xx,18{ft p typee of fill moteriale d
Latltudeflongltude source: 1TP8 DTopographla mop /
(lccalfo»ofaieXrnuptpp shown ansUSGtStopo map anrierttaohedto 11. DAT'EWELL AB.ANDONED ! rf Lr ]
this form lfnot using GPM
•
LDOHER1:DYQERTIFYTHATTHISWELLWAaABANAONI DINACCORDANCE
'4U•FACILITY name of the boning where the well b located.Complete 4a WII THIS 1 IOA NCAC 2C,WEL.L CONt3TR 'ri N STANDARDS AN&TNATA COPY OP
Of residential well,skip 40;oemloleta 4b,wall owner Wilm allan anfy,) H 8 gEE P�fID O fi LL OWNfiEt.
FACILITYI0#((reggae a) ,(✓✓ 1
NAMEOFFACILITY �[�� �,�Jr' O
A RI F . ,..._... ... �
DATE
ZEETADDREtiB .rd �4� Ala ��� -
Oily or Town � � State ci 867 QNATURE Di PRIVAT WELt.OWNIjRA9ANGON
ZipCado (TheprNutowellnwnarmustbeenIndlurduaiw nSRTNt:W[9Ll DATE
46.CONTACTP6R80 1WELLt1 p�; Inoccordenoewl:ir9oAleCAC Cr.0113.) �Ilyebandnnehlelharrsatdenlle1we11
NAME t lr�dvGl d/ f • IMI�rG r>��_______
PRINTEt1MAMBCAAP0mw An�NINGYHeWt:Lt.
STREET ADDFIESSP f'C✓,fit/e /,1tre, 5 t/7/ :
C Ah on-t,s✓C/AY22t'o
• Submit a copy to the owner and tho original to:Divlaieta of Water Quality.tnT•Grmaltlan Proceeming,
1617 Mef Service Center,Raleigh,NC 27689•1617,Phone:((r,i9)807-6300 Form OW-50
Rev.5110