Union_Well Abandonment_20230406 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well CRntractor Inform o : WELL ABANDONMENT DETAILS
v l � 0, / 72.Number of wells being abandoned:
Well CuntractorName(orwell owner rsonally abandoning well an his/harpropeny) For multiple injection or nun-n ater supply rvells ONLY }vith the some
constucllantabandanment,you can submit one form.
NC Well Contractor Certificattiion/j4umber 7b.Approximate volume of water remaining in wcH(s): / S,
a UI �-S � J �� � FOR WATER SUPPLY WELLS ONLY: � )
Company Name 7c.Type of disinfectant used: r r �14
2.Well Construction Permit#. �3 J
List all applicable well permils(l.e.County,Siate,Pariance,Injection,etc)ifhnmvn 7d.Amount Of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) i nhal Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery r: _- '•`^''�
Injection Well: 7E For each material selected above,provide imoiint of materiali,nsgd:;1
❑Aquifer Recharge ❑GroundwaterRemediation 1 (�� �/)G?l��S APR j
❑Aquifer Storage and Recovery ❑Salinity Barrier dd -
❑AquiferTest ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment p`roce`darc "
❑Geothermal(Closed Loop) ❑Tracer :?I fpJv ��4 e44.�/( J?"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) / ( /� '
A.Date well(s)abandoned:
-'zWell location:
o n Oca e
Facility/OwnerName Facility ID#(if applicable) 8.Certification:
-04
New]ownl� 4C 21073
Physical Address,City,and Zip Signature of Certified Wet Contractor or Well Owner Date
By signing this form, I hereby cerfi y' that the ivell(s)ivas(were)abandoned in
County Parcel IdentificationNo.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constnction Standards
and that a copy of this record has been provided to the well mtmer.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 9.Site diagram or additional well details:
p� c, 1 You may use the back of this page to provide additional well site details or well
ll ! "1 N�� 2 3:2�:R abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atlgch ivell catstnrction record(s)if available. For multiple it1 ecdon or non-water supply
wells ONLY u•lth die same cmtstnrctionlabandonment,you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDt#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: �� (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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.
e
6d.Water level below ground surface: 3 L) (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.for Water Sungly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft)
Form GN-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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