Rowan_Well Abandonment_20230706

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
/nY- , ail Mil c f 409 7a.For Geoprobe/DPT or Closed FLoop Geothermal Wells having the same
Well Contractor Nan (or well owner personally abandoning well rt his/her property) well construction/depth,only 1 GW,30 is needed. Indicate TOTAL NUMBER of
'IFIO wells abandoned: 1.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): -/ (gal.)
ill� ed2 Well al FOR WATER SUPPLY WELLS ONLY:
CompanyName J,�
2 7c.Type of disinfectant used: yffASida (rf
.�/��1ri
2.Welt Construction Permit#: 3 9 0 15 3 s 6
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.)if known
7d.Amount of disinfectant used: d•QZ-
3.Well use(check well use): •
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural Ol9licipaUPublic ❑ Neat Cement Grout Ord&ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) n'Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑ln-igation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Shiny ❑ Other(explain under 7g)
['Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation49 bays a�^s ""' •"k
/aal6 r , ._.P f....h
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage .J )1 0 r ?@?3
DExperimental Technology ❑Subsidence Control
p7g.Provide a brief description of the abgapznu@ht7praceduc ::'.3(Jr,'
0 Geothermal(Closed Loop) 0 Tracer r ci:;r;:�;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Paid pies cined etemoea` too" Vleofiyo/oh1 (41 I/• Cue ca III 0# 3' ,fit/atki
o � 9
4.Date well(s)abandoned: ®����3 22 enkc4� ` `/, t//ed an/A,
5a.Well location: beniViiik/ hfilie YLI be/7/CM kl C4,freci 64/4
Pe-e spfo
Facility/O ner Name Facility ID#(if applicable) 8.Certific,•<;n:
Physical Address,City,and Zip re of Certifi-:' e ontractor or Well Owner Dat
der
',if.-,'J%li' ni, 11 By signin. thi onn, I hereby cert that the well(s) was (were) abandoned in
Coun Parcel Identification No.(PIN) accord.t - ith 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:
3 ry Qo• W You may use the back of this page to provide additional well site details or well
T N O `7 cK.a abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
'6a.Well ID#: ) abandonment to the following:
Division of Water Resources,Informa,tion Processing Unit,
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6b.Total well depth: ;J 0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: P- (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 26 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 1Oc.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)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
6f.Inner casing/tubing length(if]mown): A (ft.) abandoned.
1
6g.Screen length(if known): ,X (ft.)