Wake_Well Abandonment_ (12)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed'Loop Geothermal Wells having the same
Well Contractor N e(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G�-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
�— 7b.Approximate volume of water,remaining in well(s):1� al.
NC Well Contractor Certification Number PP i g (g )
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS ONLY:
Company Name !HTH
G W-073843-2022 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 ❑Municipal/Public ❑Neat Cement Grout ><Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑ Sand Cement Grout O Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ 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 1^ n
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage `f11 4,
❑Experimental Technology ❑Subsidence Control
7g. vide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 y/Y /_ ZAIWIA
`J
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LL
4.Date well(s)abandoned:
5a.Well location:
Lennar Carolinas LLC Well #2
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
8028 Hebron Church Road, Garner NC 27529 '
P
Wh sical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
ake
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
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 latAong is sufficient) 9.Site diagram or additional well details:
35.663051 N -78.576054 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)ifavailab[e.For multiple injection arnon-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 �`' pabandonment to the following:
r
` r r'm 0 ) Division of Water Resources,Information Processing Unit,
6b.Total well depth: ;Qz (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
JUN 0 3 2 M For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) r _ above,also submit one copy of this form within 30 days of completion of well
6111%:a�1 ja`�` andonment 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
AA56e.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.
ram+
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources f Revised 2-22-2016