Orange_Well Abandonment_20231024

LL ABANDONMENT RECORD For Intenul Use ONLY:
L Wi 8 Contactor Information: WELL.ABANDONMENT DETAILS
70.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
iNdi. mraacwr (arweit owner pasmre!(y ebandoning_�vell on hislher progeny). wall conStniCtion/d th,only I GW-30�S needed. Indicate TOTAL NUMBER of
j� :A welts al�rtdvHciJ; � ,
�j t
NC W 1 Canaaotor CenNicam tatiba io"Approxirmie vaiume vi waixi rciiru►ui iu wwisj:��_,�i )
Z FOR WATER SUPPLY WELLS ONLY: ��
m Name u] (Gl Co
p"� 7fr Type ordisiohrdaat used• _3 ra
2.Well Construction Permit#:
List all appliLabfa well convtraalan permits{r a i11('.(•oaa(y.Srcre Parlance,etc)trbau n
7d.Amount of distnreetant used:
3:Well use(check well use):
Water Sappty Welk 7L Sealing materials rued(check ail list a y):
OAgricuitural 0 uniaipaUPublic .R Neat Cement Grout Bemonite Chips or Pellets
OGeothern al(HeatingiCoolingSupply) l> idential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑industriall0mmercial OResidential Water Supply(shared) 0 Concrete Grout ! ❑Drill Cuttings
Q[rriamon 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry O Other(explain under 7g)
i monitoring oRecovery,
ecttob wdl; "Ili ear.each material seledkdabove;provide amount of materials used:
1�E'.yi;..r..vrrnwg+. UGf011IinRtatef:ifem0n ?.. . . �� .
unyuiivt ow+agwwfuncwvmy uoannuy nctiiiir
OAquiferTest OStomlwater Drainage
OBrtperimetnal Texhtuology OSubsidenceCordrol
OGaothamat(Closed Loop) p7}a 7&Provwa dr oil of abauilogment precedui
OGeothermal(Heating/cooling, t1t?thet` lautlnider2 x',
I
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4.Date well(S)abaad'D =.•r
Facilityi0arnaNar.+s -F; :y'it?l:Crfap�asxstc} RCOa' �G;,`.;�"°:� i_r„!
Pt fv*--c4wk-
s Sur £crti@l3:Wei1 phymw
Contractor or wen Owner Date
--u-�a --�- �,�.,,�•t•- ���.x �+,�' � g .rs:farm.I lvreby cenW,,dw the iveU(s)was(Were)abw dmred in
coply ■ c f�l 'm-a �r �i+awn DISC_.
Svi .irj...h n�sea.uEa..`DISC w AX hill.YYeii cofisr"W10ft&.0m r*
rr: ..+r....r..a...o u...ote ui�r..�.o.,w�/mte.�..lso�i +_ 7t3da cttpyof Bits record has bsen providedta-0W weAowner,
-o-------- —_-__�or�cii�+cl•• r
(ifwelt field.oirc tat/long issafficieaU � •
'��e ii�itrt or ruddiNo�l�r'di deplii�
'Ivtt#pay use rule back of this page tb provide additional well site details or well
N onment details You may also h additional pages if necessary.
CONSTRU 01\ E 411I 0F•WELUSI BEING slt•NDONED
Aaarkirel/puiarr+tcr�sr_�;: C�s}y'rfi r.Fbrmalttp la h,J ec rlon�tmn-tvmers spPlytrrlls & NRONSI ;W= S I
QNLI'w/i&i�kesama cneis .�t.yom eansybmrr orte form.
I0s."For All ens; Submit this form within 30 days of completion of well
64.Wdl Ink abaridonmentto theTollowirtg:
Divishro o)'Wner.Resource%laftmation Processing Unit:
6b.'totd well depth: ,,;s,$ _ 169=H*Serwice Center,Raleigh,NC 2/699.1617
` 1W—Var Ini etion Wells: in addition to sawing the form to the address in l0a
6r BorohokdF>iupeter. {ifr.) above.also submit one copy of tuns form within 30 days of compktion of well
abandonment to.the following:
6d.Water kvd belowground surface: + '} Division of ftterResourem Underground Injection Control Program,
W6 Malt Service Center,RdeiRh,NC 2709-1636
6e.onto �wgin�tonaN.
+'•- - .::
a (es)above aisle sabmit one copy of this'form within 30 days of complexion
seaabandwrient to the cowity health department of the county where
6L Itlaercasin8/tnbtnSku�(irl��r); (it.) .. .
6g.Screen knob(if kpawn)c Q' (it.)
Form Gw-30 iaruthCarsrna Depamnem of EnviromnCntal QisaTily=Division of water itesaar � Redised z 2T 2t))b
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