Columbus_Well Abandonment_20231228 (23)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS
1.Well Contractor Information:
1 �SLt"� For
Number of wells being abandoned
4�6 i
�— For multiple injection or non•walerl supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property)
cominictionrabondonnient,you can submit o,eform
7b.Approximate volume of water remaining in well($):
NC Well Contractor C rtifi anon umber
J�+ � ��� FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name
2.Well Construction Permit
List all applicable well permits(i.e.Cmrnty,Stare,variance,Injection•etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing mat raalsused(rbeckfllstWintonite
Water Supply Well: ❑Neat CementGFpt t .,ti �,�� Chips or Pellets
❑Agricultural ❑Municipal/Public ❑ Dry Clay
❑ Sand Cement Gro�jt t�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Concrete Grout "E L 2 8 20B ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) ❑,(,ravel
Cl Specialty ro t Vw0je a Pfor
ss�:I p Uhl
❑Irri ation ❑Bentonite Slurry p�Ili rQi3O0 ❑ Other(explain under 7g)
Non-Water Supply Well:
❑Monitoring ❑Recovery 7E For each material selected above,,provide amount of materials used:
Injection Well:
❑Aquifer Recharge froundwater Remediation ()yG�,
[]Aquifer Storage and Recovery ❑Salinity Barrier L� LpJS� j3f�.� ��1✓Gf
❑Aquifer Test ❑Stormwater Drainage l
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
( ❑Tracer � OU)'el c3`�` l6 e4,&J1-& `�42 d�
❑Geothermal Closed Loop) UGt
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) __]
tl�v���!/ /)/l f l 1 G� �✓
4.Date well(s)abandoned: _
�OctA,•
Sa.Well 1 lion: � I
,1 �1G� Oy 8.Certifies n:
F cility 1Dil(if applicable) n14��L
Facility/Ow er Nae !2- L 1/��
C /L'' (�
06 �C ��0 �6Eu�t
N1�yl,; �Q,
Sigilalu ofCerti ed Well Contractor or Well Owner Date
Physical A dress,City,and Zip P10-rce/-MCO �)�I,� By signing this form,/hereby certify that the well(s)was(were)abandoned in
lL tJ Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 WeH Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(ifwell field,one lat/long is sufficient) 1
Q you.may use the back of this page to,provide additional well site details or well
N J b a jf 2 p, W abando ment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL S BEING ABANDONED SUBMITTAL INSTRUCTIONS
Ai(ach well colutruclion record($)if available. For multiple injection or non-wafer supply
welly ONLY with the saine construction/abandonment•you can submit one form. 10s. For All Wells: Submit this form within 30 days of completion of well
U��C, 'J i _3 abandonment to the following:
6a.Well I1 V f J Division of Water Resources,Information Processing Unit,
'( 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: (ft.)
10b.For infection Wells: In addition to sending the form to the address in 10a
�w��r�6r✓ 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 v ' (ft.) 1636 Mail Service Center,Raleigh,NC 27699•1636
1 pwiy, loc.For Water Sunoly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): j/� (ft.) the addresses) 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 casing/tubing length(if known): (ft•) f'
6g.Screen length(if known): v ! v" �D �� (ft.) f
North Carolina Department of Environment and Natural Resources-Division of Water Resources
Revised August 2013
Form GW-30