Clay_Well Abandonment_20230419

WELL E3StDLiiltdl+Oly1PHlLNT RECORD For lnteraaIUsc0XL
m L Well Contractor Information: WELL ABANDONMENT DEVILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells,having the saute
Well Contractor Name or well owner personally abandoning well on his'her-property) well constructionide th,only 1 G\Y-30 is needed. Indicate TOTAL NUMBF,R of
wells abandoned:
NC Well Contractor Certification Number 7b,Approximate volume ofwater remaining in well(s):
FOR WATER SUPPLY WFLLS ONLY:
Company Name V�u pp
7c.Type of disianfectant used:_t 2.5 56.� l m Or'�,
2.Well Construction Permit 9; 022— V 2 d
List all applicable well construction permits(i.e. UIC,County,State,F•'ariance,etc.)ii known `
7d.Amount of dasumfectanfuscd: I '1 Q ll on
S.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
❑Geotheral(Heating/Cooling Supply) . (�ltesidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
01ndustrial/Commnmercial ❑Residential Water Supply(shared) GsP Concrete Grout ❑//Drill Cuttings
❑Irri gation ❑ Specialty Grout R GMN'al
Non-Water Supply Well: ❑ Bentonite Slurry VOther(esplahm tender 7g)
01%4onitoring - — �❑itzcovzry.
Injection Welh4 i4. v --.'�I° 7£For each material selected above,provide amount of materials used-
[I
AquifzrRecharge {{�i 2Q23 ❑GrotmdwaterRemediation Gffivel- - /ate ir&—k�,LMD.1
❑Aquifer Storage ajA'R ry l' ❑Salinity Barrier p(� �51��111 V
❑Aquifer Test ^� '°� ,;.; kp$formwater Drainage
❑Espzrimzntah3'ebluiolq ;>e�;:�;�Ay ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Hearin Cooling Return) ❑Other(explain under 7g) ) lf/Z W
tie
Awetl
4.Date well(s)abandoned: C)S L.12 W ( 9
5a.Well location: Q Q
Facility''Owner Name Facility ID4(if applicable) 8, c [�•
25(a V J ONXI n4 ZVI ga�c vi l I e,,ABC 2SgC 1 9 3-1
Physical Address,City,and Zip s• mat o ertified Well Contractor or Well Owner Date
l •�n� S�IQ������� By signing this fibrin, I hereby certify that the wells) was(ivere) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC.'4C 02C.0100 or 2C.0200 Id,'ell Constntction Standards
and that a copy of this record ha's been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laVlong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or welt
0f u2•5-.. 1 $ .7 J_ ' - - - �V abandonment details. You may also attach additional pages ifnecessarv.-- -
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITT_4L INSTRUCTIONS
Attach well co sMiction record(s)ifavoilable.Foir multiple infection or non-watersupply wells
ONLY with the sane conrtnictioniabandonment,you can submit one form.
10% 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,
66.Total well depth: M0 (ft.) 1617'Mail Service Center,Raleigh,NC 27699-1617
10b. For Ianiecti$n lPells: In addition to sending the foram to the address in 10a
6c.Borehole diameter: (m.) above, also submit one copy of tlmis form within 30 days of completion of well
abandonment to the following:
6d.Water level below-round surface: Division off Water Resources,;Underground Injection Control-Program, `
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.ForWater Suanly&Injection Wells: In addition to s ending.the-form to the
address(es)above,also submit one copy,of this fora within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner cas%ngItubing length(if known): NIA (ft) abandoned. `
6g.Screen length(if known): MIA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22=016