Wake_Well Abandonment_20231024

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.WelContractor Informatio : a WELL ABANDONMENT DETAILS r
Number of wells being abandoned:
For
Numb g
Well Contractor Name(or well)owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the some
qconstnrction'abandonnrent,you can svbnrilr one form_
1 7b.Approximate volume of water remaining in well(s): tf (gal.)
NC We 1 o trot Ce 'Station Nu bar E
FOR WATER SUPPLY WELLS ONLY:
VVV �7 t
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permits O.e.Couny.State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply We11 7 eating materialsused:(checkall_that a
❑Munici al/Public t Cement Grout . %,_i-g ;; ; ' • tonite Chips or Pellets
❑Agricultural p
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout Dry Clay[I Concrete Grout O C j d2(�23 ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared)
��
❑SpecialtyGro�ut ,r:;^� ra ❑Gravel
DIrrigation
Nod-Water Supply Well: ❑Bentonite Slurry DI i;%- �760ther(explain under 7g)
onitoring ❑Recovery
jection Well: 7f.For each material selec ed above,provide amount of materials used:
1 -
❑Aquifer Recharge ❑Groundwater Remediation '
❑Aquifer Storage and Recovery []Salinity Barrier 201
❑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)
4.Date well(s)abandoned: Z Z, i'9 ek
i19t%y
g
Sa.Well location: ��jfi l.r U o'" 1
ID# rfapplicable)
8•Cert* anon:
Facility Facility/Owner Name (
Physical ddress,City,and Zip Sr ure of Ce 'fie Wel4onu.actor
or Well Owner Dale
Wake By signing this form, j hereby cert#5,that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.01i00 or 2C.0200 Well Construction Standards
and that a copy of this record has been or
to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For mahiple injection or non-water supply
wells ONLY with the same construction/abandonrnent,you can submit one form. 109. For All Wells: Submit this form within 30 days of completion of well
- abandonment to the following:
6a.Well ID#•
I Division of Water Resources,Information Processing Unit,
g 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: i.
lob.For Iniection Wells: In addition to sending the form to the address in 10a
10 above,also submit one copy of this,form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c.For Water Suooly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft•) the address(es) above, also submits one copy of this form within 30 days of
completion of well abandonment to!the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
I I
6g.Screen length(it known):
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I .