Union_Well Abandonment_20231204 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETALL:S
f
7a.Number of wells being abandoned:
Wel mrnctor Name(orwell owner personally abandoning well an his/her properly) For multiple injection or non-water, supply wells ONLY with the same
qconstructionlabandomnent you can submit one form.! 7b.Approximate volume of water remaining in well(s):y�ISU(gal-)
NC WellContractorC catioaNtrmber ,
FOR WATER SUPPLY WELLS ONL i
Cui pp- ry Name 7c.Type of disinfectant used:
2.Well Construction Permit 9:
List all applicable well permits(i.e.County, tale,Variance, njection,etc)if!mown 7d.Amount of disinfectant used:
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Agricultural ❑Municipa]/Public
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ). Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under.7g)
❑Monitoring ❑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 ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
4.Date well(s)abandoned:
5a.Well location:
t
l,�,o nor
Facility/Owner Name © Facility ID#(ifapplicable) 8.Cer' tin: — ���
AA 14 4
Physical Address,City,and Zip ` Signature f C 'fied Well Contractor or Well Owner Date
By signing t 's form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell mvner.
5b.Latitude and longitude to degreesfminutestseconds 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 t provide additional well site details or well
N `I W abandonment details_ You may also attach
tach additional pages if necessary_
CONSTRUCTION DETAILS OF WELLfSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constriction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same consiructionlabandonmem.you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well IDN:
✓ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
6b.Total well depth: w
(oil 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter (in. above,also submit one copy of this
is form within 30 days of completion of well
abandonment to the following:
f Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (D.) 1636 Mail Service i eater,Raleigh,NC 27699-1636
10c.For Water$UPPIy&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): -LA V (/1 CI 1 (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 Inncr casing/tubing length(if known): ll�_(ft.)
6g.Screen length(if known): (ft)
i
Farm GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABAND RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well ontractor Information. WELL ABANDONMENT DETAILS
7a Number ofwells being abandoned:
�--c� For multiple injection or non-water supply wells ONLY with the same
Well Contractor Name(onvefi owner personally abandoning well on hisltrer property) constructionlabandonmeni,you can submit one form.
7b.Approximate volume of water remaining in well(s): )? (gal•)
Ng—well Contractor Certification Number
5 FOR WATER SUPPLY WELLS ONLY•
Company Name 7c.Type of disinfectant used: i+u_
2.Well Construction Permit#: a 1 ! p
List all applicable well permits(i.e.County,State,Variance,Injection )ff9own 7d.Amount of disinfectant used: 1
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that app )
❑A F�cultural or icipal/Public ❑Neat Cement Grout Bentonite Chips or Pellets
g Supply) Supply(single) ❑Sand Cement Grout ! ❑Dry Clay
❑Geothermal(Heating/Cooling Su i ZRmsidential Water S 1
❑Industrial/Commercial esiential Water Supply(shared)
❑Concrete Grout ❑Drill Cuttings
❑Im 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: Is
❑Aquifer Recharge ❑Groundwater Remediation
❑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 J r D� ��� :Fj� � 1---1PJ C 1�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1�-- C-0 i
Lo
4.Date well(s)abandoned:
5a. ell locatign:
w�G ID# if Ircabla "this
n-r
J 2023
Facility/Owner ty aPP )
Ph sic 1 Address,City,and Zip �] I �j Contractor or Well UwiriSr'" aze
—1 ! 03,3 reby certify that the we71(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constniction Standards
and that a copy of this record has been provided to the well termer.
56.Latitude and longitude to degreesiminutesiseconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
1� f _ !S� You may use the back of this page to provide additional well site details or well
t/f—)r►I l/T_\), yj� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple rrdection or non-water supply
wells ONLY with the same constructionlabandonmem,you can submit oueform. 10a. 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
66.Total well depth: (tt)
( 10b.For Iniection Wells: In addition to sending the form to the address in 10a
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:.-. ___ O 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Suonly&Iniel lion Wells: In addition to sending the form to
6e.Outer casing length(if known): A (A f1�^_(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 casingitubing length(if known): (ft.) j
6g.Screen length(if known): (tt)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Watei Resources Revised August 2013