Vance_Well Abandonment_20230505

WEL T Jam[f'o4 lForltUseONLY:
1.Weil Ceeteaetor 1 tmsdon: WELL ABANDONMENT DETALA
1s0 n rb Q I ee 7a,For GeoprobelDPT or Cbeed-I.00p Geothermal Wells having the same
1Ue Cc^ 1%hymp(w cur omonely rbendonine well on hisIher oronan �yt well o� only 1 GW-30 is needed. bulimic TOTAL NUMBER of
�j}l�(j� wells abandoned: i
NC Well Contractor Certitkation Numb) 7b.Approximate volume of water weaa ula is wedt{s): 0 (gad.)
a rA d,/ po bit, wpm ¶ r�rn ( o. FOR WATER SUPPLY WELLS ONLY:
Compaay Nome PI '-1
7t Type of(lgand:eat mad:
2.Well Cunatrueden Permit#:
Liss apappleeehis LW/cwrxrrrrerlow Pamirs A111.C om*,Scare.Variance.era)If brown
741.Amwat of disinfectant used: _/ I I r
3.WM arse fleece well u se -'
Met Supply Weil: — 7e.Salkog materials used(cheek,nil that*Pq30
°Agricultual a unicipaltPublic C Neat Cement Grout lir Bentonite Chips or Pellets
DOeathennal(Heating/Cooling Supply) if esidentiai Water Supply(single) ❑ Sand Cement Grout C Dty Clay
Omelet iaUComme cial ❑Reskiantial Water Supply(shared) 0 Concrete Grout 0 Drill Ctatinga
Cori• •'. 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite slurry a other(explain under 7g)
Mary-
n"„^: f 7E For each material selected above,provide amount of materials used:
i� i_iCiroundwater t enie4tsri0t1 ! has e-
DAqui&r Stotaoe and Recovery 0 Salinity Bonier 1 �
DAquifer Tact OStormwater Drainage ' 1, vrinh i f i ( i 5 I„L'
DExpavneatal Technology ❑Subsidence Control
❑Ocothemal(Closed Loop) OTnacar 7g.Provide a brief description of the abandonment preeednnt
C:hottietaal(He thigfiaoling Return) 0Other(txalain under 7g) i r a U 1,f 1 i 1 I L ts
t yr�
1 Date..zegc)ebs de red: Cl'ir )-3 ^^vv 6 5 2 /
44
Ss.W s�r^, �uOs
(1) Sl01 r Orne.S n .3
Pall owaa Name Peaky IDd(ifagphcetk) &Certification: ,
X 135 r, pi Va I La kei r a [�'�' iL.. 2 d- 2-3
wearet•a.Ow. zit) Neh(�fLfsa(1 Sigastaee of%-• Weil Ce or Wen Owner Dm
ki ell(—el By sivalag this form t hereby car*that the well(s)was(Sere)alusodosed In
Camay ?aerxi ionittan NV.ir"`/ acCOrrilnrte wftlt 13A NCAC OZC.0100 or IC.UUUU Well COnainictIon Stcntdards
and that SIN Latitude mad iatt;ltada is deRreensain teahaaeads or dadotdeegrea a copy reties record has banprovi dad to the well atvr,er.
(If rreil full ono 1st/long is serfe6ens) 9_Site Moor rn or additional walll d:teile
i4 W You may use the back of this page In provide additional well site details or well
abandonment details. You may also Mach additional pages if necessary.
CONST1UJCTI9N DETAILS OF WELLtSI BEING ABANDON SUBMITTAL INSTRU T1'IONI
ArrackwdfamodnKHanrtcord(4(jarnllable.For mwtrtplatrgecrlonorxa-worertoPPIywas
ONLY Weir imam maw,obandosunem,jou nan.nibmir one form.
10a. Far AU Wghp Submit OM; form within 30 days of completion of well
y. war trim. fl abmdonmrnt to the following:
u Dh.tslon of Water Re soafte s Uni c,information Processing
6b.Total wen depth: 1 0 ER.) 1617 Matt Service Center,Raleigh,NC 274994617
6c.Borehole diameter: ‘7 pa.) IOb.Fo f1rlectton Wes: In addition to sending the form to t e address in 10a
6e.9oatbokdiameter. V (In.) above,also submit one copy of this form within 30 days of completion of weir
�1 abandonment to the following:
6d.Water level below ground surface: �`'g (Q,) Division of Witte Resources,Undar{roltad injection Control Program,
1636 Mee Service C.eateer,ReltdgY,NC 37699.1636
el 1
tit.Outer casirig ter (afriu): rail
(A 1@,_Far`tlr,n..Rnnnly k Intense n Wear: In addition to sending the form to the
adtll'esEp)1bpga also submit coin eyfln,of this form within 30 days of gOttlpi6ti0n
0of well abandonment to the welly health department of the county where
6f.ltlaeraeinEfttddag length cif knouts. (ft.) abandoned
eft.Screen lens or known) 0 (II.)
Fenn OW-30 North Carolina Department of Environmental QaAtty-Division of Water Resounoo Revised 2-22.2016