Davidson_Well Abandonment_20220930

yy JCtLL AlIDA DONltrll n',N!i- For faterml Use ONLY:
This form can be used for single or multiple Avells
L Well Contmetor Information: WELL ABANDONMENT DETAILS
Reuben W.Clayton, III 7a.Number ofwells being abandoned:
Well ConuactorNane(orxenQ%%merpcwnailp abandoning well anlas/herpropem) For mulaple ttjectlan or amrimrer supply wells ONLY mfth the save
2241-A wustnrclian WW'donnrenr,you mnsubmit aae jam.
NC Well Connactor Certification Number 7b.Approximate volume of water remaining in wdl(s): /2-0 (gaL)
Aqua Drill, Inc. FOR WATER SUPPLY'%7ELLS�ONLY:::Compatn Fame / 7c.Type of disinfectant used:
2.Well Construction Permits: ~ 2.2~`/
List all applicable nrli pennas(u Comth:state,frorianre.Injection,ent)yybinw
7d.Amount of disinfectant used:
3.Vi/ell use(check well use):
Water Supply Well: 7e.Sealing materials used(cheep all that apptv):
❑Agricufitaal ❑M icipal/Pabiic ❑Neat Cement Grout ElBentonite Chips or Pellets
❑Geothermal(HeatinslCooling Supply) dential Water Supply(single) ❑Sand Cement Grout ❑DrV Clay °"r-a=�- ,
❑IndustrioUCommercial oncrete Grout "'OResidential Water Su ly(shared) � ❑Drill Cuttin ��'�t k•..s d
❑Irri ion ❑Specialty Grout ❑Gravel Sc FP 22
t �0
Non-WaterSupplytirell: ❑BentoniteSlumy ❑Other(eaplainundeP7g) ' Ll
Monitoring ORccwvery `�.,,
Injection Well; 7E For each material selected above,provide amount of thi WW
❑AquiferRectrarge ❑GronndnaterRemediation
fi`u�ikaQ'y
0AquiferStorage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StomnNmterDminage
❑Experimental Technology ❑Subsidence Control 7g,Provide n brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/CoolingReams) ClOther(ccplain under7g) ✓'TlJtatr�9 � " ��El��`t' �i ar° �°1�.� '
4:Date well(s)abandoned: /���g•�t.�.� �`C�$ „s�,. � d ' '� r
Sa.Well location:
FaeiligdOwner Name ;r—wty me(ifapplieabrc) S•Certifcation:
Physical Address,City,and Zip - Signaaaa ofC ttificd Well Contract or Well thvaer tram P
By-T191 ng Ads form I hereby CerfifT that the'well(s)nos(1-re)abandoned in
County Parcel ldernification No.(PIN) accordance with 15A AIMC 02C.0100 or 2C.0200 Well Construction Standa/rlt
and drat a copy of Ws record has been provided Io lire well turner.
Sb Latitude and longitude is dcgrccs/trtinuteslsecaads or decimal degrees:
(ifwc,l field,one fatilong is sufficient) 9.Site diagram or additional well details:
PP s r ° p�� �r t��d��.��p �P You may use the back of this page to provide additional well site details or%vela
..7" 6 UGC ° abandonment details. You may also'attach additional paves if necessary.
CONSTRUCTION DETAU S OF WELLIS)BEING ABANDONED SUBMfiTAL INSTRUCTIONS
Attach oven comimclimt recard(sj if arallobte. her mtthiple injection or nanarater supply
rdisONLYWth/hesamrcnnsrnrc►io)rnbatrdnnment,poncansnbnrironeform. 10a. For All Well Submit this form%vidtin 30 days of completion of well
62.Well ID#• abandonment to the following:
? Division of Water Resources,Information Processing-Unit,
6b.Total well depth: c/ (fL) 1617 Mail Service Cctrter,Rateigb,NC 27699-I617
10b.For Inicetion 3i7eILs: In addition to sending the form to the address in 10a
tic Borehole diameter � rn) 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 .� ({y) Division of Water Resources,'Underground Injection Control Program,
1636 Mar Service&nter,Raleigh,NC 27699-I636
IOr-For Water Smuniv&Inieeti I Wc71r. In addition to sending the form to
tic Outer casing length(if known): (ft) the address(es) abovq also submit one copy of this form within 30 days of
completion of%veil abandonment to the county health department of the couruy
where abandoned
6E Inner casingitabing length(if lmown):