Rowan_Well Abandonment_ (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYS$ 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 wells ONLY with the same
construction/abandonment,you can submit one form.
A - 4121 1 .
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1 5 (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name %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 thata ly).
[]Agricultural ❑Municipal/Public ❑Neat Cemen-Got- o ')�� ❑tentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout A U G s 20Z2 ❑ Drill Cuttings
❑Irri ation ❑Specialty Grout .aGravel
Non-Water Supply Well: ❑ BentoniteM -' nEpu E:1 Y�f Cvir54lt Sr.
O pp y ther(explain under 7g)
oMonitoring ❑Recovery D%,!e,Vj-60G
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.25 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 well(s)abandoned: 06/06/22
- - 5a.Well location:— --- — — — -- - - - - — -- -
ATLANTIC PETROLEUM
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
1614 EAST INNES STREET SALISBURY 28146 06/15/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
ROWAN 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 ivell 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:
350 39' 05.78" 800 27' 21.39" You may use the back of this page to provide additional well site details or well
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(s)if available. For multiple injection or non-tivater supply
wells ONLY with the same consiruction/abandonment,you can submit one form, 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 11.0 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Sunniv&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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013