Wake_Well Abandonment_20221014

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells O C T I !
WELL ABANDONMENT DETAILS L
1.Well Co tractor Informaho
Gy HSGt<l� 7a.Number of wells being abandoned: -w
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY .9 the same
construcuo✓abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): D�r` (gal.)
NC Well Contractor Certification Number
PC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: n
2.Well Construction Permit#: J�f
List all applicable well permits(i.e.CounO,,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: I
3.Well use(check well use):
FOAgricultural
ell: .�7y Sealing materials used(check all that appl ):
❑Municipal/Public Meat Cement Grout <Bentonite Chips or Pellets
Heating/Cooling Supply) ❑Residential Water Supply(single) /❑_Sand Cement Grout ,❑�ry Clay
mmercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
N n-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
Konitoring ❑Recovery
7f.For each material selected above,provide amount of materials used:
'Injection Well: �/�,/./
[]Aquifer Recharge ❑Groundwater Remediation Ly ,k' '6 AYie d ' �s/1S. 1-y P©/e v u�
❑Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage \ lfl
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer
t
N t+ � t^ IV'
t)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 72)
Co* NI a 1,03Aar c� ^eo, 6Lvrta dtcu� F �acQ
4.Date well(s)abandoned: o Z� Y., Be
/
5a.Well location: /1 . r � (r-E/jIG1ill�e� D l�d ✓e" "a(�/l�'J91 &ese_ 4'4'1
old ��tl�l .1��1611 ol/rl N ! 1`� G�r�L e� lewelb)
8.Certificati n
Facili DOwne�2�am� � Facility ID ifapplicable) 1
�y y IA 01
Physical Addr ss,City,and Zip A/ Signatu o ertifie We I Contractor or Well Owner Date
wt- Q /V By signing this form, I hereby certify that the wells) 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:
You may use the back of this page to provide additional well site details or well N r Q G W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recordist tf available. For multiple injection or non-water supply
wells ONLY with the same constructionlabandomnent,you can.submit one fonu• 10a. For All Wells- Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#• ff
W i
I Division of Water Resources,Information Processing Unit,
¢ 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: S o
10b.For Injection Wells: In addition to sending the form to the address in 10a
®14 above,also submit one copy of thisiform within 30 days of completion of well
6c.Borehole diameter: 0 fin.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
0�� ft. 10c.For Water Supply&Injection Wells: In addition to sending the form to
fie.Outer casing length(if known): ( ) the address(es) above, also submit�otie copy of this form within 30 days of
completion of well abandonment to Ithe county health department of the county
where abandoned.
6E Inner casing/tubing length(if known):
6g.Screen length(if known): ✓n JCYJ0LAJ, (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Res uri es Revised August 2013
I