Wilson_Well Abandonment_20220805 (2)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.W I Contractor Information: WELL ABANDONMENT DETAILS
I. 7a.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or we o� wner personally abandoning well on his/her property) well constructioa/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gat.)
FOR WATER SUPPLY WELLS ONLY:
Company Name (,,
7c Type of disinfectant used:�ie Q(�Y l
2.Well Construction Permit#: q
Gist all applicable Kell construction permits(.e.UIC.CowtOt State,Variance,etc.)if,@nmvn I I
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgricultural ❑Municipal/Public 0 Neat Cement Grout p Bentonite Chips or Pellets OG p '
eothetmat(Heating/Cooliog Supply) ❑Residential Water Supply(single) M Sand Cement Grout q/6ry Clay R��E B�Q En
Ol/ndustriaVCommercial OResidential Water Supply(shared) ❑Concrete Grout —O//Drill Cuttings
4— w E..f
ation ❑Specialty Grout li Gravel AUG 0 2022
Nou-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
Monitoring ORecovety )f1fCr9na tan Prmeaeattg Unit
Injection Well: 7f.For each material selected above,provide amount of materials used:
Injection
DAquiferRecharge OGroundwaterRemediation `IL l C`Q'/
OAquifer Storage and Recovery OSalinityBarrier /lam \ `f
❑Aquifer Test ❑StormwaterDrainage ' TOY1 cn av�1
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer i
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date weB(s)abandoned: —1 ,
5a.Well location:
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Facility/Owner NaruJ Facility[DO(ifapplicable) 8.Certifi ti n: I
blgl lAw� SAS S- &n46n huj ,Nc, z7 3 7 ZQo ZZ
Plhy^sisal Address,City,a Zip Signature ofCcnified Well Cottractor or Well Owner Date
�'1 r' ' By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with,1 SA NCAC 02C.0100 or 2C.0100 Well Construction Standards
and that a copy of this record has been provided to the%wil owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) r 9.Site diagram or additional well details:
N 71. bZ�,(i.�D W You may use the back of this page to provide ladditional 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)iJamilable.For multiple injection arnon-watersupply twlls
ONGYwithrhesamecaurructionlebandonment,you can submit oneform. 102. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID9. abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depthr- t _(ft.)' 1617 Mail Service Center,Raleigh,NC.27699-1617
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10b.For Injection 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:
6d.Water level below ground surface:_ 10 _(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):' (ft.) loc.For Water Supply&injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this fomt within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (fit,) abandoned.
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6g.Screen length(if known):
Form GW-30 Nonh Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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