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Home My WebLink AboutMcDowell_Well Abandonment_20221208 (3) WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Inf{o�rmation: 1 J WELL ABANDONMENT DETAILS grG q 7a.For Geoprobe/DPT or Closed(Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of q wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of wate remaining in well(s): (gal.) T'cr!'GLO() ton So L" n FOR WATER SUPPLY WELLS ONLY: I Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits(z.e.UIC,County,State,Variance,etc.)ifkn own 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e. aling materials used(check'all that apply): ❑Agricultural ❑Municipal/Public lS eat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Ceme t GCr"t ' ❑Dry Clay ❑Industrial/Commereial ❑Residential Water Supply(shared) ❑ Concrete toot)-- ; % i� ]Drill Cuttings ❑hri ation ❑ Specialty Grou �t r� ❑Gravel Non-Water Supply Well: ❑Bentonite S1urr�F V 8 2022 ❑ Other(explain under 7g) ❑Monitoring WRecovery Iniection Well: 7E For eac r t ail f riafi 14cit�d a"bov �`rov&amount of materials used: 35 �iwl `' ` "��' ❑Aquifer Rechazge ❑Groundwater Remediation C��`,. c ❑Aquifer Storage and Recovery ❑Salinity Barrier• •�a �qA � ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer � ❑Geothermal(Heating/Cooling Return) / /e) ❑Other(explain under 7g) aC4 Cam e4 A� Refrt bo 4om o� .wsl) d�o �o io /V 4.Date well(s)abandoned:_ w 21 ZO Z 2 1 , w; }C;M/►'z, a to e, 5a.Well location: P6o 6w Pm,�ru V 2 ZA4,* 7760 Facility/Owner Name Q Facility ID#(if applicable) 8.K:;�� )y1.1.7 VS 22) Nar� AZ Physical Address,City,and Zip Signature of Certified Well ontractor'or Well Owner Date Mt:Dow e') By signing this form,I hereby cert that the wells) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record hasibeen provided to the well owner. 56.Latitude and longitude in degrees/minutes/seconds ort decimal degrees: (ifwell field one lat/long is suffitegt) Mq^ nG 1LJCCl 9.Site diagram or additional wen details: N r 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. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)ifavallable.For multiple injection ornon-watersupply wells ONLY with the same construction/abandonment,you can submit oneform. z 10a. For All Wells: Submit this form within 30 days of completion of well 6a..Well ID#• R J abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 5C) (ft) 1617 Mail Service"Center,Raleigh,NC 276994617 10b.For Iniection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: (in,) above, also submit one copy of;this form within 30 days of completion of well abandonment to the following: I 6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 276994636 6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the address(es)above,also submit orie copy of this form within 30 days of completion of well abandonment to the county health department of the county where 6E Inner casing(tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): (ft.) i Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL AKANDOAA LNT RECORD For Internal Use ONLY: 1.Well Contractor Information: f WELL ABANDONMENT DETAILS D re,4 urn�Tf a 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GWd30 is needed. Indicate TOTAL NUMBER of wells abandoned: 1 I i NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): (gal.) Ter rci on ton S y) 1-a„kS Xn r, FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit M List all applicable well construction permits(1.e.UIC,County,State,Variance,etc)if known 7d.Amount of disinfectant used:�. 3.Well use(check well use): Water Supply Well: 7e.waling materials used(check all that apply): ❑Agricultural ❑Municipal/Public Teat Cement Grou , t ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply ❑ Sand Cement I o "" "'° .. Q21 Cla � � g PP Y) uPP Y t��..,,� � �B U.,..ter?,; Y ❑Industrial/Commercial []Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings Irrigation ❑ Specialty Grout DEC 0 8 2024 Gravel Non-Water Supply Well: / ❑Bentonite SlurrT r_-r .; ether(explain under 7g) OMonitoring @Recovery R+vrr+e:.+t�� Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation 35 a,1 601 ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑ 5x 1 Aquifer Test ❑Stormwater Drainage a ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer y� n ❑Geothermal(Heating/Cooling Return) 170ther(explain under 7g) /}r�/am Cgy�1n� teX `1 I 1 P.�L �`W►'l F' ,�I/ T1b� Db9'Td11�1 OTI l�G�� o '�Op 4.Date well(s)abandoned: Ay 2,1 �ZD 2'L 5a.Well location: Raot bow Po,,,�ru V 2 Xn&* -7760 Facility/Owner Name Facility ID#(if applicable) 8.Ce •6cation: Iy1T7 VS 221 /Vary t1 22 2Z Physical Address,City,and Zip Signature of Certified Well ontractor or Well Owner Date /r't:DO(/J ell By signing this form,I hereby certfy that the well(s) was (were)abandoned in County Parcel Identification No.(PIN) accordance with ISA 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: f (if well field one laUlong is suffi�,gt) mr p �,�`IUd 9.Site diagram or additional Well details: N 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. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attachwellconsimctionrecord(s)ifavailable.For multiple injection or non-watersupply wells ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a..Well ID#: abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: �0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection 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: (in.) abandonment to the following: 6d.Water level below ground surface: 00 Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 00 10c.For Water Suooly&Injection Wells: In addition to sending the form to the address(es)above,also submit onelcopy of this form within 30 days of completion of well abandonment to the county health department of the county where 6C Inner casing/tubing length(if known): (ft.) abandoned. 6g.Screen length(if known): (ft.) j Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016