Union_Well Abandonment_20231006

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G. I30 is needed. Indicate TOTAL NUMBER of
Cwells abandoned:, e�
NCntrar Certification Number 7b.Approximate volume of water iremaining in well(s):Well Co
Morgan Well & Pump, INC FOR WATER SUPPLY WELLSi NLY:
Company Name ranulated chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well constructionpermits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: rl 'L
3.Well use(check well use):
Water Supply Well: 7e:Sealing materials used(check all that apply):
❑Agricultural ❑ umcipal/Public ❑Neat Cement Gi(pUt ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑ S d Cement Cri6.u�'--'�.���'1; t� 'y-..lj bWClay
''
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑bnll Cuttings
❑Initiation Specialty❑ S ecial Grout O C T a G'2023 ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Sl 1 ❑ Other(explain under 7g)
❑Monitoring ❑Recovery G� ;; ;�
Injection Well: 7f.For each material selected"0. �,Yprovide amount of materials used:
❑Aquifer Recharge. ❑Groundwater Remediation
(/ ..arols
❑Aquifer Storage and Recovery ❑Salinity Barrier V
❑Aquifer Test- ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonme7trocedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) l /ow
ft
4.Date well(s)abandoned: y./,/ rowCr lA Pea-
Sa.Weft location: &CA 0,("Tr
Va i d &11V A,
Facility/Owner Name Facility lD#(if applicable.) 8.Certificati0
qyaq { Ir��S ro C� R� '[�Jian Tri 9 /�
Physical Address,City,and Zip tgn a of Certifi �. J
C ctor or Well Owner Da
/O/f By signing tl hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PEST) accordance with 15A MCA 02C.0100 or 2C.0200 Well Construction,Standards
and that a copy of this record has beets provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) r
9.Site diagram or additional well details:
Oq N � W You may use the back of this page to provide additional well site details or well
`1 0. abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)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 form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: X abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (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: (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): X (ft.) 10c.For Water Sunnly&Iniecti+n Wells: In addition to sending the form to the
address(es)above,also submit one bopy 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 Cif known): (ft,) abandoned
6g.Screen length(if known): >( (ft.)
I
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised-2-22-2016