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WELL ABANDONMENT RECORD For humid UseONLY: 1
I
1.Well Contractor lsnformatioo: WELL ABANDONMENT DETAILS
1 fl A t"�,1r ,JR 11 n @. 7a.For GeoprobedD PT or Closed-Loop Geothermal Wells having the same
Weil Contractor Name or well o veer personally abandoning a Il on his/her pro' petty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Z) s-a-
wells abandoned:•
NC Well Contractor Certification Number 7b.Approximate volume of water rermaiaing in well(s): (gal.)
gu ip ki r& �tt -1- eJ V i FOR WATER SUPPLY WELLS ONLY:
Company Name ( Ile
! 7c.Type of disinfectant used:�,...�,
2.Well Construction Permit N: f&S D '- /Q-D !8 3
List all applicable well pvrotneetion permits(i.e.U(C,County.State,Variance.etc)if karma O
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sea materials used(check all that apply ,
❑Agricultural ❑Municipal/Public Cement Grout ll>J tonite Chips or Pellets
❑Geothermal(Heating/'Cooling Supply) .•t sidentia)Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
Olndustrial/Commereial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑lrr igatirn - .-'.--• •", 0 Specialty Grout ❑Grovel •
Non-Water Su p(y Wellf;17,, , 1 j SSlum/,.•' 0 Bentonite Slu ❑.Other(explain antler 7g)
❑Monitoring �- ' r,,' "" �� ❑Recovery
Injection Well: ` el (0 2 37 m
3 7f.For each material selected above,provide amount of materials used:OAquiferRecharge 3 ti J ❑GroundwaterRemediation e._`1 P.'
t tl'.A
❑Aquifer Storage and Recovery.,t..-;::�,'TSSnlinity Barrier
:.: :x.rY.'; S , is
OAquiferTest-l�{,; {. `•��.��;,_:_- • ❑StolmwaterDrainagc 1f1C�e�
❑Expesimextlal Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ClTraccr Q ���� `L�re-
.F
°Geothermal Bleating/Cooling Return) ❑Other(explain under 7g)
j i\X�$ W: u-r
4.Date well(a)abandantxl: --3—:.� /i/ 3C-1,401- 001 A-re 6. .
5a.p»R`eid location: e(\-1e,t. (A)L' \o teN Y e• v e,
v A$tIAkAlkU\k ffiniton:
Facility/OwncrNane Facility tD B.Certf(applicable) i
L,?a? Qouc eCTet c�t.C, f,�V�ttligsivri(lc ,---ty -e...,_-(2.2,' - .-.1 l°i^`3
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PTT• By signing this form,I hereby certil}'that the well(s)was(were)abandoned in
County Parcel IdentifiicationNo.(PiN) accordance with ISA MAC 02C.0100or2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude In degrees/mrleuteslseconds or decimal degrees: -
(if well field,one hi/long is sufficient) 9.Site diagram'or additional well details:
j ) /r "7 / ., 171 W You may use the back of this page so provide additional well site details or well
V'� r�� N '! / abandonment details. You may also attach additional pages if necessary.
CCINSTRUCrION DETAILS OF WELIASI BEING ABANDONED SIJBMi"ITAI,INSTRUCTIONS
Attach well caasrniction,eeord(s)ifavailablr_For m::ltipin Injection ornon-routersupplyWeill
ONLY aiM the raise cnsz ,crionfa&znthrnmcsrt.you can xirbarll wwf/rrm. 10a.For MI Wells: Submit this form within 30 days of completion of well
6a.Well IDN: abandonment to the following:
•
Division of Water Resources,Information Processing Unit,
6h.Total well depth: '7 5 (ft.) - 1617.Mail Service Center,Raleigh,NC 27699-1617
IOb.For inicxtitrn Wells: In addition to sending the form to the acd Ness its,I Oa
6e Borehole diameter. (G.) above;also submit one copy of this form within 30 days of completion of well
abandonmentto,the'following:
6d.Water level below ground surface: /LC. (ft) Division of Water Resources,Underground Injection Control Progreos,
..1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): S (ft.) 10c.For Water Sour*&loiectiou Wells: In addition to sending the fcnn to the
address(m)above,also submit one copy of this form within 0 days cf completion
of well abandonment to the county health depermmen f the county where
fif.Inner casing/tubing length(if known): (ft.) abandoned
a j c cffippi ,.
t� r
6g.Screen length(if known):Li. ` 7•s (ft.)