Stanly_Well Abandonment_20230807 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
'1 ,,�� a��. 7a.For Geo robe/DPT or Closed-Loop Geothermal Wells having the same
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Well Contractor Name(or well owner personally abandoning well on his/her property) well constriction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
.7?- 2. --
7b.Approximate-volume of water remaining in well(s):_(gal.)
NC Well Contractor Certification Number
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j FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: 1
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if(mown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ANeat Cement Grout ❑Bentonite ChikVR?,llets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
XMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test 0Stormwater Drainage Zee—2 f G
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: _
❑Geothermal(Closed Loop) ❑Tracer /a dt 01 2-L I ��
❑Geothermal(IIeating/Cooling Return ❑Other(explain under 7g)
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4.Date well(s)abandoned: ?
5a.Well location:
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Facility/Owner Name (fFacility ID#(if applicable)
y� S.Certification:
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Physical Address,City,and Zip rf� j 2- O 0 K Signature of Certified Well Contractor or Well Owner Date
CCi7 By signing this form,I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachwellconstructionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: �� �� 5r e`/'l. /l/ abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
6b.Total well depth: 2 (ft.)
10b.For Injection Wells: hi addition to sending the form to the address in 10a
6c.Borehole diameter:/1 (;n,) 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): P�Iti iLd G'�(ft) 10c.For Water Suonly&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
abandoned.
6f.Inner casing/tubing length Qf known)): (ft)
69.Screen length;(if known):�/r L (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016