HomeMy WebLinkAboutWELL-11-10-13335.TIF Mar 09 11 11:53a Scott Gantt 7044347212 p.1
. F;.
_L: w ,s': ABANDONMENT RECORD
;� '' North Carolina Department of Environment and Natural Resources- Division of Water Quality
`"` WELL CONTRACTOR CERTIFICATION # 2584A
1. WELL CONTRACTOR: 5. WELL DETAILS:
ALAN S. GANTT a.Total Depth 20 ft. Diameter. 36 in.
Well Contractor (Individual) Name b. Water Level (Below Measuring Point): 13 It
CAROLINA WELL DRILLERS, INC. Measuring point is 0 ft. above and surface_
Well Contractor Company Name
522 GANTT'S GROVE CHURCH RD 6. CASING: Length Diameter
Street Address
MOORESBORO NC 28114 a. Casing Depth (if known): NO CASING ft. in,
City or Town State Zip Code b. Casing Removed: ft. in.
(704 ) 434-7277
Area code Phone number 7_ DISINFECTION: 64 OZ
2. WELL INFORMATION:
(Amount of 65 %75% calcium hypochlorite used)
SITE WELL ID d (if applicable) WELL -11 -10 -13335 8- SEALING MATERIAL:
Neat Cement Sarni Cement
STATE WELL PERMIT 1 (if applicable)
Cement lb. Cement b.
COUNTY WELL PERMIT * (if applicable) Water gal. Water gal.
Bentonite
D W Q or OTHER PERMIT * (if applicable)
Bentonite Ib.
WELL USE (Check applicable useJ Monitoring PI Residential
Type:U Slurry U Pellets
0 NI unlcipaUPubtic 0 IndustriellCommerclal (-1 Agricultural Water gal.
U Recovery U Injection 0 Irrigation Other
O Other list use) ) Type material GROIJr
3. WELL LOCATION:
Amount 5.75 YD
COUNTY CATAWBA QUADRANGLE NAME
NEAREST TOWN: DENVER, NC 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
4849 HWY 16 N LACEMENT BY CONCRETE
(Street/Road Name, Number, Community, Sulxtvision, Lot No., Parcel, hp Cade) TRUCK
TOPOGRAPHC !LAND SETTING:
I1 Slope 0 Valley ;/i Flat U Ridged Other
(Check appropriate setting) 10. WELL DIAGRAM : Draw a detailed sketch of theeil on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 ° 35 ' 221000 • DMS OR 3X.xxxxxxxxmo in the well, gravel interval, intervals of casing pertorattons, and depths and
LONGITUDE B1 • 5 • 28.6000 • DMS OR 7X.XXXXXXXXr O types of fill materiatsned
Latitude/longitude source: VpPS Dfopographic map ti. DATE WELL ABANDONED 3/6/11
(location of well must be shown on a USGS logo map andatlached to
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The nacre of the business where the well is located. Complete 4a: THIS RECORD HAS BEEN PRVIDED TO THE WELL OWNER.
(Ira residential well, slip 4a; complete 4 b. well owner information only.)
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FACILITY ID # (if applicable) �� 3/8/11
NAME OF FACILITY SIGNATURE OFC RED WFI CONTRACTOR DATE
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner nut be an Incividual wbersonallobandortis his/her render Iial well
in accordance with 15A NCAC 2C .0113. )
4b. CONTACT PERSON/WELL OWNER: ALAN S. GANTT
NAME BANDY'S CROSS ROADS VFD PRINTED MARIE OF PERSON ABANDONING THE WE LL
STREET ADDRESS 4849 NC 16 HWY, MAIDEN, NC
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing, For, GW -30
1617 Mail Service Center, Raleigh, NC 27699 -1617, Phone : (919) 807 -6300 Rev. 5/10