Surry_Well Abandonment_20230315

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WELL ABANDONMENT RECORi For Internal Use ONLY•
'ell Contractor Infor Lion: WELL ABANDONMENT DETAILS
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d414l /Y! ' 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Veil Contractor dame(or well owner personally abandoning well on his/her property) will construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
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,r7 wells abandoned:
• NC Well Contractor Certification Number� 7b.Approximate volume of water remaining in well(s): (gal.)
i ,, FOR WATER SUPPLY WELLS ONLY:
Company Name Az 7.94 7
2.Well Construction Permit{t:PR&L.ADoZ2O 34294 7c Type of disinfectant used:
list all applicablewell construction permits 0.e.MC.(Munn i,mit Stare.I'ariance,etc.)Orono .
7d.Amount of-disinfectant used: Ph
/I Vh
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3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public eNeat Cemetji Grour,- ;, 0 Bentonite Chips or Pellets
❑Geothermal(HeatingiCooling Supply) lfesidential Water Supply(single) 0 Sand Cement Grout W,e)a._„- -;( 1—D Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout D O Drill Cuttings -
❑Irrigation x El Specialty GrouM�n 1 5 2023- 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurs; Blither(explain under 7g) 4. 74 K�
❑Monitoring ❑Recovery n�,- ,,;i ,.. ,._
Injection Well: 7f.For each material-selected;513bve,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Rem ediation ♦/►
e-'444. ' -,c154•Ci
❑Aquifer Storage and Recovery,. ❑Salinity Barrier • /7v
❑Aquifer Test ❑Stormwater Drainage ea 6,/1 L- ''-98 , ,
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: c " 7-.2 3 - _
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5a.Well location: S
5D 3 f EOCA rei Ad .
Facility/Owner Name Facility!DO(if applicable), 8.Certification:'
Physical Address.City,and Zip iallekerod-re of Cented Well Co r or Well Owner Date :
StA rrl i=_- •
By signing this Arm, 1 hereby ce.rts that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 114 Ar(A('02('.0100,or 2('.0200 Well('onstruction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal'degrees:
(if well field.one lat/Iong3aAicient)CP G /f 9.Site diagram br additional well details:
.J•6 O/e, Z e N �-d 3. ' 2, - ' You may use the back of this page to provide additional well site details or well
W
v .� - abandonment de,tails.__You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)8LING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction region/(s)ifarailahle.:For multiple injection or non-,rarer supply wells
ONLY with the.same canslnntion abandonment.con can submit one,franc
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10a. For All Wells: Submit this fq ti within 30 days of completion of well •
6a.Well ID#: Pru)L 2vaav 31,94 abandonment to the following: I
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^ Division of Water Resources,Information Processing Unit,
66.Total well depth: �eL (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617
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: O (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): f,'"'-". (ft.) . Ilk.For Water Suanly&Injection Wells: In addition to sending the form to the
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addresses)above.also submit one 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-)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-20tu

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