Pender_Well Abandonment_20220822

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply hells ON midi the same
construction/abandonment,you can submit one form.
A - 4475 3.5
7b.Approximate volume of water remaining in well(s); (gal•)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Munici al/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Agricultural P
❑ Sand Cem&tGrottt', . 'rr= 0 Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) a w_ y ,,d ; lr�
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑ Concrete Grout �❑ Drill Cuttings
❑Irri ation ❑ Specialty GroulA UG 2 2 2022 ❑ Gravel
Non-Water Supply Well: ID Bentonite Slurry ❑ Other(explain under 7g)
In
❑Monitoring ❑Recovery iii°'rvies:'DC- 1�f C:rz, '45{� Ura l
7f.For each mate rialsileclid@iove,provide amount of materials used:
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 5.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date wells)abandoned: ...
08/11/22
5a.Well location:
JOHNSONS CORNER GRILL
8.Certification:
Facility/Owner Name Facility ID#(if applicable) `-
9031 US - 421 CURRIE 28435 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this form, I hereby certify that the ivell(s)ivas (were) abandoned in
accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Comity Parcel Identification No.(PIN)
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 lat/long is sufficient) 9.Site diagram or additional well details:
78� 03 02.30 You may use the back of this page to provide additional well site details or well
340 27' 27.25" N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(v)if available. For multiple injection or non-water supply
wells ONLY with the scone construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
AS-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
30.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
1Ob.For Iniection Wells: In addition to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: 2'0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 7'0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013