Wake_Well Abandonment_ (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well C ctor Information: WELL ABANDONMENT DETAILS
i�/� 7a.For Geoprobe/DPT or Closed-ILoop Geothermal Wells having the same
Well Contractor Name(dwell owner personally abandoning well on his/her property) well construction/depth,only 1 G 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:_
NC Well Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): (gal.)
N.W. Poole Well and Pump Company FOR WATER SUPPLYWELLS'ONLY:
Company Name HTH
G W-075555-2022 7c•Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout >�Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout 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
❑Aquifer Storage and Recovery ❑Salinity Barrier !�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7 vide a brief description of the abandonment procedure:
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❑Geothermal(Closed Loop) ❑Tracer 1
❑Geothermal(Heatin Cooling Return ❑Other ex lain under 7 ® Yt � w -g-41—
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Date well(s)abandoned: ,® A�o, ELL=40W I � o
a.Well location: ��� ����
Concord WP Col Morrisville LLC
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
610 Airport Boulevard, Morrisville NC 27560
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Ph sicaake l Address,City,and Zip lure of�hified Well Contractor or Well Owner Date
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwetl field,one 1atAong is sufficient) 9.Site diagram or additional well details:
35.849653 N -78.827203 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.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#: abandonment to the following:
a Mr
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 (ft•) ,►UN 0 3 202? 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above,also submit one copy of this form within 30 days of completion of well
pj2 Q nment to the following:
6d.Water level below ground surface: A) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (ft•) 10c.For Water Supply&Iniection,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
6f.Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): ® (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016