Person_Well Abandonment_20221122

WELL ABANDONMENT RECORD
For Internal Use ONLY:
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I.Well Contractor information:
ABANDONMENT DETAILS
Ci�i L i
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hislher property) well eonstruetion/depth,only I 6W-30 is needed. Indicate TOTAL NUMBER of
ys'>7 7 sq wells abandoned:
NC hell Contractor Certification Number 7b.Approximate volume of water remaining in well(s): t>O aL
Company Name FAmount
PPLY WELL$ONLY:
ectant used: T(-1
2.Well Construction Permit#:
Lirt all applicable well construction permit•(i.e.U/C:(bu try.State.t artonce,eta)iftpw>ra
infectant used: 0 Z
3.Well use(check well use):
Water Supply Well:
OAgricullural �e` ealittg materials used(check all that apply):
❑Municipal/Public PP Y)
❑Geothermal(Heating/CoolingSupply) �- Neat Cement Grout O Bentonite Chips or Pellets
upP y) 19Residential Water Supply(single) ❑Sand Cement '� r yt K.
01ndustrial/Commercial L,-t, >•: � ; V Patty
❑Residential•Water Supply(shared) O Concrete Grout
❑(rri lion � � ❑Drill Cuttings
Non-Water Supply Well: O Specialty Grout NOV 2 2 20221 Gravel
❑Monitoring ❑Recovery 0 Bentonite Slurry J ,V ? ❑Other(explain under 7g)
injection WcIk IrlioTIM�."i r.r:.^q�3 Rg Uri;:
DAquifer Recha ❑Groundwater Remediation 7f.For each material seleci ' °vpvidc amount of materials used:
1
❑Aquif:rSto.c and Recovery ❑Salinity Barrier 3oy 1�S POC'�-�nneJ
LOGeothermal
uifer Test OStormwater Drainage
perimental Technology ❑Subsidence Control
othermal(Closed Loop) OTracer 7g.Provide a brief description of the abandonment procedure:
(Heatin oolin Re um) ❑Other(er lain under 7 P
4.Date well(s)abandoned: w-17
5a.Well location: }y 3 ' be�os� e- C Mtn W j-1-�
demon Q cad L�S1�c►�c 7a
Facility/Owner Name Facility ID"(ifapplicable) S.Certification:
14fgS OXford Qd �1Cboro N� a�s7y
Physical Address,City,and Zip 1d_I�7 a r1
Signature OfCCM11ed Well Contractor or Well Owner Date t d
County By signing this
Parcel Identification No.(PiT) Arnt, /hereby certify dial dire ulell(s)was(were)abandoned in
ac-rdance 111111 15A A'CAC 02C.0100 or 2C.0200 Well Constwction Standards
5b.Latitude and longitude in degrees/minutea/seconds or decimal d and that a copy of this record has been provided to the ircH turner.(ifwoll field one lat/long is sufficient) egrees:
34-v ao' (p t 1 v e 11 9.Site diagram or additional well details:
y N 7 03 W You may use the back of this page to provide additional Well site details or Well
abandonment details. You may also attach additional pages if necessary.
CON$TRUCTiON DETAILS OF VVEt i�cl RFIIyC ABA O( n
Alraehur!/cnnrinicnonrewrd(sJ jmnriabia 1 armrdnpieinjeciiannrnan irotersn lviie//s SUOMI rTAt INSTRUCTION
Oft I'uith the same consinrctiomahandanment.yore can submit rate fr)rtn. Pp
6a.Well iD#: ton. For All 'I Ve11s: Submit this form within 30 days of completion of well
N��( abandonment to the following.
6b.Total well depth: o tJ
Division of Water Resources,information Processing Unit,
I f (g,) 1617 Mail Service Center,Raleigh,NC 27699-1617
�� lOb.For Infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: (in.) above,also submit one copy of this form Within 30 days of completion of well
abandonment to the following;
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6d.Water level below ground surface: tx S (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
t ;.
6e.Outer casing length(if known): N S loc.For Water Cur..
(ft.) Iv&iaicctioit Wells: in addition to sending the form to the
address(es)above.also submit one copy of this form within 30 days of completion
6E Inner casingitubing length(if known): N l A (ft.) abandon d abandonmentof well to the county health department of the county where
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6g.Screen length(if known): A)s1 ri (ft.)
Forth G W-30 Nonh Carolina Depanment ot'Er-vironmentnl Quality D' f
Q ry-Division of water Resources Revised 2-22-2016
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