Wake_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor 7OKwood
mation: WELL ABANDONMENT DETAILS
If?
arc 7a.For Geoprobe/DPT or Closed)-Loop Geothermal Wells having the same
We]I Contractor Nhme(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW�O is needed. Indicate TOTAL NUMBER of
fq(//� g,_ t1 wells abandoned:
NC Well lcontractor lCertification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS r'ONLY:
e
Company Name 1HTH
G W-071604-2021 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 l b.
7d.Amount of disinfectant used:
3.Well use(check well use):
i
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
❑Irri ation �ecialty Grout PGravel
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 ❑Groundwater Remediation 17 A r•- {,ryl ^r
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7pppp���Aprovide a brief description of the abandonment procedure:
❑Geothermal(Closedoopl g ❑Tracer ) tx� r J6d" A � ���
❑Geothermal(Heating/Cooling Coolin Return ❑Other(explain under 7 ,F
4.Date well(s)abandoned:
5a.Well location:
EEM Phase 2 Land LLC
Facility/Owner Name Facility ID#(ifapplicable) 8.CeMeation:
2006 Wake Forest Road, Raleigh NC 27608
P i Address,City,and Zip Signature ofC a Well Contractor or Well Owner Date
Wlake
By signing this form,1 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 beet:provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.808318 N -78.624168 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#: F -onment to the following:
4 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) J U N 0 3 2022 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells- In addition to sendingthe form to the address in 10a
6c.Borehole diameter: ✓t�> 't � ve submit one w of this form within days of completion of well
(in.) . afP � �a I >bi PY Y P
L u`�1�i�rrY hM ent 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
6e.Outer casing length(if known): _(ft,) 10c.For Water Supply&Liection 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.
I
I
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016