New Hanover_Well Abandonment_ (8)

WELL ABANDONMENT RECORD For ImemaI Use 0.LY.
1.Well Contractor Information: RF.I,L ABANDONMENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
t%'ell ContractorName(or well owner personally abandoning well on huther property) well construetiowdepth.only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2725-A wells abandoned:
ell Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 (gal.)
ET FOR RATER SUPPLY WELLS ONLY:
Y"' �,-' '�.-•mil`°r�„.. �,
ompany Name 7c.7•ype of disinfectant used:
fa 2l2`
2.Well Construction Permit 1
List all applicable Kell constnrction permits(i.e.u1c,C",1'-'h.Ntute Variance.at�Ct.Lt rn
--'- t�t.•s 7d.Amount ofdisinfectant used:
3.Well use(check well use):
Rater Supply Well: 7e.Sealing materials used(check toil that apply):
jAgrieultural ❑Nfunicipal%Public N Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Sand Cement Grout ❑ Dry Clay
❑IndustriaLCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurr}' r Other(explain under 7e)
M%lonitorini, ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 15 Ibs portland cement ^-1 gal water
❑Aquifer Storage and Recovery []Salinity Barrier `
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop) ❑Tracer Removed well cover and concrete pad. Filled M W
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
with neat cement through tremie pipe. Restored ground
4.Date well(s)abandoned: 8/18/22 surface.
Sa.Well location:
Former Winter Park Cleaners DC650013
Facility/OwnerName !IT, [D- (ifappliciblei S.(ertifieation:
1437 College Rd, Wilmington 28403 j 8/18/22
Physical Address,City,and Zip — -
� I�antractor or lk w Date
Oner Data
New Hanover
av signing this frni. I herehv certify that the itell(s) was overe) abandoned in
Counn Parcel Identification No.(PIN) accordarrea irtth 1 5-i NC.-IC 0Y'.0100 or?C.0_00 lVell Construction Standards
and that a-opt of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat'long is.sufficrerin 9.Site diagram or additional well details:
34 12 38.740 N 77 53 11.443 . You may use the back of this page to provide additional well site details or well
abandonment details. You mac also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
4ttachwellconstnictionrecord(s)ifavailable. Formultipleinjecdonornon-watersupplcwells
ONLI'oath the same conshuction.,dbando tment.you can suhnut ate/in•rn
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IIW: M W-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18 (ft.) 1617 Mad Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1 (PVC) rn) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Rater level below ground surface: �9 (ft.) Division of Rater Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (t•) 10c.For Water Supply&Infection NL•ells: fit addition to sending the form to the
address(es)above,also submit one copy of this form"ithut 30 days of completion
of well abandonment to the county health department of the county where
6C Inner casing/tubing length(if known): 8 (ft,) abandoned_
6g.Screen length(if known): 10
Form GXV-10 North Carolina Department of Environmental(Quality-Division of Water Resources Re%*Bed 2-22-2016