Durham_Well Abandonment_20230526 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1:Well Contractor Information: WELL ABANDONMENT DETAILS
L' k‘ \-\kX\C:9C3„ 7a.For GeoprobeJDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name =11 owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
r)el t"`07 NC Well Contractor Certification Number 7b.Approximate volume of water remaining inwell(s):__.. (gal.)
t
(A)AeC T `trnTe .:� /\C-e C. e- FOR WATER SUPPLY WELLS ONLY: `�,.^
Company Name li 7c.Type of disinfectant used: NAB ilY1 - "�r ' \\
L.Well Construction Permit#: ���v++� .
List all applicable well construction permits(i.e.ma Cou :SJatg,r )Gf 7d.Amount of disinfectant used:
� Y�4,..., 6 Y J
3.Well use(check well we): MAY �'d+ �
Water Supply Well: 6 2.0 2 J 7e.Sealing materials used(check all that ap�
❑Mupj�alj c ❑Neat Cement Grout Bentonite Chips or Pellets
❑_ cultural Tn,ti,,.r. r'f: xeGs1 i 111
❑Geothermal(Heating/Cooling Supply) ❑Re hal W$ n. pl (single) 1B41 nd Cement Grout ❑Dry Clay
❑Industrial/Commercial ' stidential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irrigation 0 Specialty Grout 12 ravel
Non-Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recover'
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Li-r c57 e -0971 111
❑Aquifer Storage and Recovery ❑Salinity Barrier M L 1 _ � , �1
❑Aquifer Test ❑Stormwater Drainage .. I(0R_ i 1 _ f Icliets C. -
❑Experimental Technology ❑Subsideoce Control 7g,Provide a brief
ydescription of the abandonmentj procedure:
❑Geothermal(Closed Loop) ❑Traces �e1` f `�r 1 _ (��' ("MyJ7 f+i �t'�-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r' 1 4C) 1.1
y ` Pb f6\ � '40' /) - [,�i.Sa gtt \e (A)] 1(
4.Date well(s)abandoned: ( 1 "' c&r "/1 NA-C&r en- nci-c7Az (e '
tvel
5a.Well location (A l"ICJVI, Cgsjn j C O4S �' -4"A5 5 f OCr4
e\& 6C 4 - ,
Facility/Nnff Name Facility]D#(if applicable) 8.Certification: `
0D ( ( G a IN mAm P os ire .2
Physical Address,City,and Zip Yet t 'ms 0 Signature of Certified W erns or Well Owner Date
� ) 0717-tom� ' el- By signing this form,I hereby certify that the well(s)was(were)abandoned in
1 Parcel Identification_No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy(Phis record has been provided to the well owner.
5b Latitude and longitude in degrees/minutes/seconds or decimal degrees: ----
(dwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
a -5737Q 7Q t '"J�L�✓1 You may use the back of Ibis page to provide additional well site details or well
Q N 8 I 7 Cd� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(SI BEING ABANDONED ,SUBMITTAL INSTRUCTIONS
Attach well constructionrecords)ifavailable For multiple injectionor non-water suppfywells
ONLY With the same eonstruction/abandonrnrent you can submit one form. 10a For All Wells: Submit this form within 30 days of completion of well
6a.-Well ID#: I et
abandonment to the following.
Division of iVaterReso>aces,Infomzriatfio Processsh t;
6b.Total well depth: - (ft.) -
1617,Mail Semvlee Center,Raleigh,NC;2769916L7,J
10b.For Infection Wells: Tn 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
6�Borehole diameter: (in.) above,
to the following.
Division of Water Resources,Underground Injection Control Program,•
6d.Water level below ground surface: ( ) 1636 Mail Service Curter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 10c.For Water Simply&Infection Wells: In addition to sending the form to the
(ft.) 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
6L Inner casing/tubing length(if known):4 A (ft.) abandoned. 1
6g.Screen length(if known):
Alf A (rt) 1