Chatham_Well Abandonment_20220627

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
�M sz o 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
�L�'Y1y T '� _ FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)iflarorvtr
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 ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑hri 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 Z YIV!2 D 1� 1tiLLL j✓{, CC L- �-
❑Aquifer Storage and Recovery ❑Salinity Barrier n/1 ,�
❑Aquifer Test ❑StormwaterDrainage 4f/M t:OZ-� t"oL.R_ n�i"/" /� /"1
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
n
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) !P 12L-Yl1tTLL /✓IF7 1 r2d>t'1
4.Date well(s)abandoned: � (,�Z
.y`Ytl6�L��O
5a.Well location:
AN N S p/vt
Facility/Owner Name
� Facility ID#(if applicable) 8.Certification:
,S 2i /�.JC'�\ I`tut . C 1C2 fG2C /-L- l( Zo��
Physical Address,City,and Zip - a oftur C rti d ll ontractor or Well Owner Date
rI T_I '
7VJ By signing this forin, 1 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �"'
well fie ,one laon +
(if field, t/lg is sufficient) 9.Site diagram or additional well det9iils�r�-�ti''�•�s�� �^ --•'
N W You may use the back of this page to provide additio I we ite details or well
abandonment details. You may also attach 6 _ _ cessary:
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Prccv,—�rtg Unh
Attach well construction record(s)ifavailable.Formultipleit#ectionornon-water supply wells {nQDi7ti3(t31 t
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#: 1y/t abandonment to the following:
�7 o Division of Water Resources,Information Processing Unit,
6b.Total well depth: ��J (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
/' I► 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: V (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: �1 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): �K✓�fx� (ft.) 10c.For Water Supply&Injection 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): NM' (ft.) abandoned.
6g.Screen length(if known): LA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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