Wake_Well Abandonment_20230406

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.W ll-Contractor for R D. n WELL ABANDONMENT DETAILS
�/(�// 7a.Number of wells being abandoned:
W ontractor ame(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
canstnretiarJabandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well �nt-racto Certific�Number/I - �� FOR WATER SUPPLY WELLS ONLY:
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Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well perntits(i.e.County,State,variance,injection,etc.)ii(known 7d.Amount of disinfectant used
3.Well use(check well use):
7e.Sealing materials used(check all that apply): �- T, ;
Water Supply Well: Neat Cement Grout ❑ Bentonite Chip-.t,..rPellets
❑Agricultural ❑Munici aUPublic ❑ and Cement Grout ❑D ryClaY
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
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❑ Drill CuttinAPR V t9 ����
❑ Concrete Grout `
❑Industrial/Commercial OResidential Water Supply(shared)
❑ Specialty Grout ❑ Grayph, y
❑Irri ation ex lain;undei 7
❑ Bentonite Slurry Other( P g)
Non-Water Supply Well: ,•;. " t:.:
Monitoring ❑Recovery
7E For each material select ab ve,provide amount of materials used:
action Well: (/ /rt d
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❑Aquifer Recharge ❑Groundwater Remediation (� �5 z ffT D t (O 4 II Pow 11 wd I
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❑Aquifer Storage and Recovery ❑Salinity Barrier 3` v
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❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descrip on of the abandonment rocedpre:
❑Geothermal(Closed Loop) []Tracer V��S 0 fl L a G (/l G( l r7 6��l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 0 t,(l"d n e / "�/
4.Date well(s)abandoned: l/`� G/Vj / v�
TG C04440A
Sa.W,gel�locatt ne: U— 8.Certi
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fic ott� Add— "0 LS
Facility/Owner Names^ F cility ID#(if applicable)
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Physical Address,C ity,and Zip qp Signature of Certified Well Contractor or Well Owner Date
2 Qr)l�a I o By signing this form, !hereby cerli,that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 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: 9.Site diagram or additional well details:
(ifwell field,one lat/long is sufficient)
� You may use the back of this page to provide additional well site details or well
N 13 S o W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wall construction record(s)tf avmlable. For mulnple injection or non-water supply
wells ONLY with the sate constr tctionlabandontnent,you con.subtnit one form• 10a. For All Wells: Submit this form within 30 days of completion of well
S_ abandonment to the following:
6a.Well ID#
• Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
l 10b.For Infection Wells: In addition to sending the form to the address in 10a
(J ��f/1�/ � (tn above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: ) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
� )�vLl j/f it 10c. For Water Supply&Injection Wells: In addition to sending the form to
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6c.Outer casing length(if known): ti l ( ) 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
—' where abandoned.
6E Inner casing/tubing length(if known): (ft.)
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6g.Screen length(if known): ��°t y (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013