Caldwell_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
`OSA R 11 RQ 4 A5 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
ha�,z ownts
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal,)
FOR WATER SUPPLY WELLS ONLY:
Company Name Type ���, /��
Q 7a T e of disinfectant used: y c h l6 r i A0 �73
2.Well Construction Permit#: �`7�7 V i/� 7���
List all applicable well permits r e.County,State, Variance,Injection,etc.)iflmown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaLTublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement gireut— 7�ii ry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) lncrete Grour{`:, _�.�' 3�+r dill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry •.."• n 2022 ❑ Other(explain under 7g)
❑Monitoring ❑RecoveryoF' �-1
Injection Well: 7f.For each arktlse3ect� ro a amount of materials used:
ui u[1
❑Aquifer Recharge ❑Groundwater Remediation SXcs
❑Aquifer Storage and Recovery ❑Salinity Barrier 1 l!. 1 yLl
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Trader I I[C i "t I �.{,,G (J 1� (S/f�u
�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) t �f ("I',11 �G�(d l
Q�/G�/aa- end c����� � �� d.►�f
4.Date well(s)abandoned: p DMZ°
5a.Well location:
/ p i J I"I
1 ctr�t-- I(1 fjG Cir)J Cud! cCd'71 C\(cull Gi.'1 Ilk ndCr 0,ML'4rf
Facility/Owner Name Facility 1D#(ifapplicable) 8•Certification: r
1 c� CO ifrz 11 Rd, .LW;n J1 c
Physical Address,City,and Zip _ Signature of Certified Well Contractor or Well Owner Date
CA Id f a$;oc6g74)9T
By signing this form,I hereby certify that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS _
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form_ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 96 abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3 1 A) 1617 Mail Service Center,Raleigh,NC 276994617
n L_i 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: �( I (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water-level below ground surface: O (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
© 10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) 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
6E Inner casing/tubing length(if known): (ft.)
where abandoned.
6g.Screen length(if known): © (ft)
Form GW-30 North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013