Jackson_Well Abandonment_20230807

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Adam Mitchell 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
- Well Contractor Name(or well ownerpersonally abandoning well on his/herproperty) well construction/depth,only 1 GWi 30 is needed. Indicate TOTAL NUMBER of
4353-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
AAA Greene Bros Well DRLG of Sylva, ING FOR WATER SUPPLY WELLS ONLY:
Company Name H T H
2022-24154-9-12609 7c.Type of disinfectant used: i
2.Well Construction Permit#:
List all applicable well construction permits O.e.WC,County,State,Variance,etc)iflmown 40
7d.Amount of disinfectant used: G All
r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): IJt,�,,4` •"•^ �
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bet
onit:—! 'i. ojr''Fel��snk
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring_ ORecove_ry___
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1 yd flowable fill
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pulled pump, chlorinated, filled with concrete
4.Date well(s)abandoned: 7/1 1/23
5a.Well location:
Candler Cooper
Facility/Owner Name Facility M#(if applicable) 8.Certification:
Lot 27 Indian Hills Dr � / Xg,, &,9- 3/ Z
Physical Address,City,and Zip Signature of Certified Well Contracto orViell Owner Datdf
Jackson 7614-78-8077
By 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
-83.306 N 35.454 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DE`WI OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one farm.
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,Information Processing Unit,,
6b.Total well depth: —100,
(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suonly&Infection 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
6E Inner casing/tubing length(if known): (fL) abandoned.
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016