Union_Well Abandonment_20231204

WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for.single or multiple wells
1. 1 Contractor anon: WELL ABANDONMENT DETAILS
( 7a Number of wells being abandoned: I
Well Contractor Name(or well own personally abandoning well an his/her property) For multiple injection or non-water supply ivells ONLY with the same
construcdonlabandomnen4 you can submit onefOr7n.
a '
7b.Approximate volume of water remaining in well(s): 1 � (gal.)
NC Well Contractor Certification Number n
w� �� Ak,\. FOR WATER SUPPLY WELLS ONLY:
Company Name R 7c.Type of disinfectant used: N
2.Well Construction Permit#:
List all applicable well permits 0-e.County,State,Variance,Injection,etc.)flmown 7d.Amount of disinfectant used: n 5
3.Well use(checkwell use):
7e Sealing materials used(check all that apply):
Water Supply Well:
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) a ater Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
7E For each material selected above,provide amount of materials used:
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation �/1J ��,�1✓✓Ll�
❑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/CooingReturn) ❑Other(exp lain under 7g)
4.Date well(s)abandoned: Y • • -~ aA ?` ��
5a.Well location: n�r 2023
XG 8.Certification: iI:`.:+
wn 5 ..... 1,..
Facility/Oer Name � FaciGtyID#(ifapplicable)
— ,,d J 23
_75(0 - TWtgn1!a 1 -FaCty-aw it' 2R07'
Physical�Add s,City,and Zip 1yI %CQ n l/a., Signature of ed 1 Contrac Owner Date
u Y) CD-7t)2, I,OZ�3 gy signing this form,I hereby certifyi that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Constniction Standards
and that a copy of this record has been proWded to the well m mer.
5b.Latitude and longitude to degreestminutesiseconds or decimal degrees:
(ifwell field,one tat/long is sufficient) 9.Site diagram or additional well details:
r� © You may use the back of this page to provide additional well site details or well
J.' Q� N O ' �� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMTTTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-crater supply
wells ONLY with the same constructionlabandonment,you can submit one form. 10s. For All Wells Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#•
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
6b.Total well depth: U� (it)
10b.For Injection Wells: In addition to sending the form to the address in 10a
11 __ above,also submit one copy of this'form within 30 days of completion of well
6c.Borehole diameter: V (in.) abandonment to the following: i
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: D (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
p loc.For Water Sodaly&Iniecl on Wells: In addition to sending the form to
6e.Outer casing length(if known):_ i�tJ (ft.) 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.
6E Inner casing1tubing length(if known): (fL)
6g.Screen length(if known): (fk)
Form OW-30 North Carolina Department of Environment and Natural Resoumes—Division of Water Resources Revised August 2013