Watauga_Well Abandonment_20230428

WELTONN RECORD For Internal Use ONLY: .
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
J C11- r.e s Pa)c-ki el //e/ryta n, 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
o245-17 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
,KAi b1 rot/ erS FOR WATER SUPPLY WELLS ONLY:
Company Name Un 7c.Type of disinfectant used:. �1 7c•
2.Well Construction Permit#:•c2:23Z1' /'3
List all applicable well construction permits(i.e.UIC,County State,Variance,etc.)if known 7d.Amount of disinfectant used: A-lb
b
3.Well use(checkwell use):
Water Supply Well: • le.Sealing materials used(check all that apply):
• EiAgricultural OMunicipaliPublicr : iirNeat Cement Grout • 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) _ -kesidential Water Supply(single) q Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete.Grout. 0 Drill Cuttings
❑Irrigation • •0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: • If.For each material selected above,provide aamm�ount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
•❑Aquifer Storage and Recovery ❑Salinity Barrier 2 s
❑Aquifer Test ❑Stormwater Drainage
71171
❑Experimental Technology OSubsidence Control 7g.Provide a brief descri hon of the aban
g P 'qu1' .upl0 dtii a+.c')F Luz. •
OGeothermal(Closed Loop) ❑Tracer //� / [ 4`'.`L�:�c3Q(3
❑Geothermal(Heating/Cooling Return) t diet(explain under 7g)t-/?Oa /1.., L ,�..Ltl/1)
4.Date well(s)abandoned: -*r
O-�.3. Rr►les� 7 •
5a.Well location:
pry;Ili ck c,u,It Oar a301g3 _
Facility/Owner Name Facility ID#(if applicable) .. 8:Certification: •
8.26 C/,.„4 /iarr'i5 £€ J am AirGe 7 I .?,wjn - `f�Z/. Z
Physical Address,City,and S j....tore of Certified Well C tractor or Well Owner Date
IdaTQN-g a- :y signing this form,I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 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:
(if well field,one lat/long is sufficient) • 9.Site diagram or additional well details:
JG d 14
1 1/ u N '/ L) .59 ' 22 W You may use the back of this page to provide additional well site details or well
'7" O abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-water supply wells
ONLY with the same constnrcttrn✓abandoninent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well DO: 36 hi 93 abandonment to the following:
Division of Water Resources,Information Processing Unit,
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6b.Total well depth: -/ + - (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in l0a
1 d above, also submit one copy of this form within 30 days of completion of well
6c Borehole diameter: o (iu) abandonment to the following: .
6d.Water level below ground surface: /d (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length'(if known): o,y C 5 (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the formic:the
address(es)above,also submit one copy of this form within 30 pays of completion
of well abandonment to the county health department of the county where
6>"Inner casing/tnbing length(if known): 3 5— (ft) abandoned.
6g.Screen length(if known): (ft)

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