Wake_Well Abandonment_ (14)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Wel ontractor Information:_ /',-�f/ WELL ABANDONMENT DETAILS
UIf� i 7a.For Geoprobe/DPT or Closed Loop Geothermal Wells having the same
Well Co actor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GWI 0 is needed. Indicate TOTAL NUMBER of
' wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of waterremaining in well(s): (gal.)
N.W. Poole Well and Pft Company FOR WATER SUPPLY WELLS IONLY:
Company Name HTH
G W-073499-2022 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,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
❑Irri 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 ❑Groundwater Remediation O ? 96"AWP
❑Aquifer Storage and Recovery ❑Salinity Barrier
`/ may/ t
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7WItCovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other(explain under 7
4.Date well(s)abandoned: 1
5a.Well location:
Ophelia Heirs Dillard
Facility/Owner Name Facility ID#(if applicable) cation:
8749 Glenwood Avenue, Raleigh NC 27617
Ph of
sical Address,City,and Zip Signature �Q re fled Well Contractor or Well Owner Date
V�lake
By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0160 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.
(i£well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.888016 N -78.747501 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 welts
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#: [ 1� �'�' 04(th'aGtj7ent to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: A) JUN U 3 202? 1617 Mail Service Center,Raleigh,NC 27699.1617
,10b.For Injection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: :�
(in.) � ,�,,,,,,, s�,�„C,�tagto,�tp,,�lso submit one copy of this form within 30 days of completion of well
r E?:t, n;ti:i:7;','IT tf:Jl'-It-�•abarl oit3 t nt 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&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copyi 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
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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