Pender_Well Abandonment_ (31)

WELL ABANDONMENT RECORD Far 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) ror utultiple injection or non-water supply wells ONLY with the some
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 7e.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 _--.' r *^r�
❑ Sand Ceme t-Grv�.i _ 't I❑Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ..:; 1..r
❑Industrial/Commercial ❑Residential Water Supply(shared) Grout, n
❑Concrete ut• ❑ Drill Cuttings
❑Irri ation
❑ Specialty Grout ) r I. Q L112� ❑ Gravel
RI Bentonite Slurry ❑ Other(explain under 7g)
Non-Water Supply Well: •+
OMonitoring ❑Recovery F- ,.:;.;; .�
Ur1r
7L For each Wti'tirlal's�l@eted:pba�b,provide amount of materials used:
Injection Well:
5.0 GALLONS
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test I ❑Storrnwater 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 well(s)abandoned:
08/11/22
- - Sa.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 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 lat/long is sufficient) 9.Site diagram or additional well details:
W
27.25 N 780 03' 02.30" You may use the back of this page to provide additional well site details or well
34° 27 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 saue construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
AS-10 abandonment to the following:
6a.Well ID#:
Division of Water Quality,In Processing Unit,
30.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
Job. For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 6'0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. 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
I
North Carolina p
Department of Environment and Natural Resources-Division of Water Quality Revised March 2013