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GW-1~ r�_, WELL ABANDONMENT RECORD ' North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION # 1. WELL CONTRACTOR: C.�w ' 3 &ince ­ Well Contractor (Individual) Name Well Contractor Company Name STREET ADDRESS Lt'C C l�Yi�yC GIYN �� , 71'al l City or Town State Zip Code Area code - Phone number 2. WELL INFORMATION: SITE WELL ID # (if applicable) STATE WELL PERMIT # (if applicable) COUNTY WELL PERMIT # (if applicable) DWQ or OTHER PERMIT # (if applicable) WELL USE (Check applicable use): ❑ Monitoring Residential ❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ Irrigation ❑ Other (list use) 3. WELL LOCATION: COUNTY�� QUADRANGLE NAME NEAREST TOWN: r ull ,u —kh "(( ne, (Street/Road Name, Number, Couununity, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SE1 TING: ❑ Slope ❑ValleyL� FI%at ❑ Ridge ❑ Other (Check appropriate setting) LATITUDE May be in degrees, minutes, seconds, or in a LONGITUDE decimal format Latitude /longitude source: ❑ GPS ❑ Topographic map (Location of'well must be shown on a USGS topo map and attached to this form if not using GPS.) 4a. FACILITY- The name of the business where the well is located. Complete 4a and4b. (If a residential well, skip 4a; complete 4b, well owner information only.) FACILITY ID #(if applicable) NAME OF FACILITY STREET ADDRESS City or Town State Zip Code 4b. CONTACT^^ PERSON/WELL OWNER::_ NAME c_i1V \�j �flVICQ INCY �V"e5� WU wq- STREET ADDRESS 5. WELL DETAILS: a. Total Depth: ft. Diameter: in. b. Water Level (Below Measuring Point): ft. Measuring point is ft. above land surface. 6. CASING: Length Diameter a. Casing Depth (if known): ft. in. b. Casing Removed: ft. in. 7. DISINFECTION: (Amount of 65 % -75% calcium hypochlorite used) 8. SEALING MATERIAL: Neat Cement Sand Cement Cement lb. Cement lb. Water gal. Water gal. Bentonite Bentonite lb. Type: ❑ Slurry ❑Pellets Water gal. Other Type material // (AWA Amount lC/ ( tQ S 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL: P' (Z v t��Yl 07y ll 10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this form showing total depth, depth and diameter of screens (if any) remaining in the well, gravel interval, intervals of casing perforations, and depths and types of fill materials used. 11. DATE WELL ABANDONED I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. SIGNATURE �O�CERTIFIED WELL CONTRACTOR DATE llff�tll ..YY��1111//II ii s� ppGGFFLL j'1Cz �G4 (ti �� LU^LN Ci/IMI� 3 /J7 /v SIGN T RE OF PRIVATE WELL OW ANDONING THE WELL DATE (The private well owner must be an individual who ersonall abandons his. tier residential well in accordance with 15A NCAC 2C .01 3.) PRINTED NAME OF PERSON 9 ANDONING THE WELL 60 Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Forn GW -30 Attn: Information Management, 1617 Mail Service Center — Raleigh, NC 27699 -1617, Phone No. (919) 733 -7015 ext 568. Rev. 5/06 si.arE ikc��ltia r J WELL ABANDONMENT RECORD ( North Carolina Department of Environment and Natural Resources- Division of Water Quality 1 WELL CONTRACTOR CERTIFICATION # 1. WELL CONTRACTOR: Well Contractor (Individual) Name i�ai ti:�t�Y kkufn� i-'M Well Contractor Company Name STREET ADDRESS ' CAy or Town State Zip Code (14--) - - 077i Area code - Phone number 2. WELL INFORMATION: SITE WELL ID # (if applicable) STATE WELL PERMIT # (if applicable) COUNTY WELL PERMIT # (if applicable) DWQ or OTHER PERMIT # (if applicable) WELL USE (Check applicable use): ❑ Monitoring ©1kesidential ❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ Irrigation ❑ Other (list use) 3. WELL LOCATION: COUNTY ca t 144 QUADRANGLE NAME NEAREST TOWN: C'Cu - JU'(tiYNrK (Street/Road Name, Number, Counnunity, Subdivision, Lot No., Parcel, Zip Code) TOPOGRAPHIC / LAND SETTING: ❑ Slope ❑ Valley [J-Flat ❑ Ridge ❑ Other (Check appropriate setting) LATITUDE May be in degrees, minutes, seconds, or in a LONGITUDE decimal format Latitude /longitude source: ❑ GPS ❑ Topographic map (Location of well must be shown on a USGS topo map and attached to this form if not using GPS.) 4a. FACILITY- The name of the business where the well is located. Complete 4a and4b. (If a residential well, skip 4a; complete 4b, well owner information only.) FACILITY ID #(if applicable) NAME OF FACILITY STREET ADDRESS City or Town StateZip Code 4b. CONTACT PERSCIN/WELL OWNER: NAME IAV,5 C�'I f1�Z Is oJEYiT G�f 17 STREET ADDRESS 5. WELL DETAILS: f� a. Total Depth: 07 ft. Diameter: - /�i in. b. Water Level (Below Measuring Point): _�� ft. Measuring point is 0 _ ft. above land surface. 6. CASING: Length Diameter a. Casing Depth (if known): b. Casing Removed: ft. in. ft. in. 7. DISINFECTION: (Amount of 65 % -75% calcium hypochlorite used) 8. SEALING MATERIAL: Neat Cement Cement lb. Sand Cement Cement lb. Water gal. Water gal. Bentonite Bentonite lb. Type: ❑ Slurry ❑Pellets Water gal. Other Type material Amount ` lo 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL: u '^ 10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this form showing total depth, depth and diameter of screens (if any) remaining in the well, gravel interval, intervals of casing perforations, and depths and types of fill materials used. 11. DATE WELL ABANDONED e7 I f/ I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE 06 i�cl�. j� SIGMA RE OF PRIVATE WELL OWNER ABANDC G THE WE L DAA (The privIrte well owner must be an individual who personally bandons his,her residential we in accordance with 15A NCAC 2C .0113.) � S. ep, t,--n /AJ 6r -Y' xi 4r� 01 PRINTED NAME OF PERSON A13ANDONING YE WELL Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW -30 Attn: Information Management, 1617 Mail Service Center - Raleigh, NC 27699 -1617, Phone No. (919) 733 -7015 ext 568. Rev. 5/06