Durham_Well Abandonment_20220527 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.EContractor Information: \\ WELL ABANDONMENT DETAILS
r C(' ` �1V 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name ell owner personally abandoning well on his/her property) well constmetion/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
� C1fP77-C--1
NC Well Co tractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal)
' T R SUPPLY WELLS ONLY:
Company Name 9
7�pe of disinfectant used: t 0
2.Well Construction Permit#• MAY 2: LULL
List all applicable well construction perndts(i.e.Ula Counly,State,Yananm etc)Pfknowrr_r 1 Ir�f disinfectant used•
1MYS
3.Well use(check well use):-
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mint paUPublic ❑Neat Cement Grout ❑Bentomte Chips or Pellets
❑Geothermal(Heating(Cooling Supply) sidmbal Water Supply(single) ❑Sand Cement Grout ❑Dry Clay—— - - —
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01hi ation R SpecialtyGrout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Qm rn`X .,ck
❑Aquifer Storage and Recovery ❑Salinity Barrier -�}��p ( 1�I _! � p�
❑Aquifer Test ❑StormwaterDrainage 1-t `"' 'C�J psif tfi C tfa4
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Jg 1-
t '
❑Geothermal(Heating/Cooling Return). .❑Other(explain under 7g)
4.Date well(s)abandoned:
Sa.Well location VA
Facility/Owner Name pZV1zX VW a cility Mff(if applicable) &Certification:
L 6�ft� 44cit/
4, a�2
Physical Address,City,and Zip (� �p7 Signature of Certffied Vile C6.t ctor or Well Owner I}a
�LI0 h--�gD"' 'OD—7&1 By signing this form,1 hereby certify that the wells)was (were)abandoned in
C-uoty Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ofthis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
0 rl9 B 1_q (��? W You may use the back of this page to provide additional well site details or well
N
IP CJ !(� l� abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstraclionrecord(s)ifavailable Formultipleirgectionornon-watersupplyxrlls
ONLY with the same construction/abandonment you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following.
A
\�2 Division of Water Resources,Information Processing Unit,
66b.Total well depth: (tL) 1617 NW Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter. (m) above,also submit one copy of this form within 30 days of completion of well
l abandonment to the following: .
6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
p `
6e.Outer Iasi length(if known): (fk) lOc.For Water Sutroly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6£Inner cashWtubing length Cif known): 1A Ift.) abandoned.
69-Screen length(f known): "/,4 00

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