Columbus_Well Abandonment_20231228 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J.1 G��pt. 7a.Number of wells being abandoned:
r For multiple injection or non-water supply wells
n ONLY with the some
Well Contractor Name(Orwell owner personally abandoning well on his/her property) constructiowbhondonment,you can submit one form.
. 3q _ 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well contractor certification Number IV S
FOR WATER SUPPLY WELLS ONLY: Jr[�]—
7c.Type of disinfectant used:
Company Name �j
2.Well Construction Permit
List all applicable well permits(i.e.Corrn%State,Variance,Injection,etc.)jknou"' 7d.Amount of disinfectant used:
3•Well use(check well use):
7e.Sealing materials used(check all that apply):
Water Supply Well: enonite Chips or Pellets
❑Neat Cement Grout � t p
❑Agricultural ❑Municipal/Public 1 "�—�"'" Dry Clay
pp y(single) ❑ Sand Cemat c"rrot 'E V
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su 1 - r r ❑ Drill Cuttings
❑Concrete Grout
❑industrial/Commercial Residential Water Supply(shared) GALL
• ❑ Gravel
❑ Specialty Gro 1. 2 8 2023
❑Irri ation ❑Bentonite Slurry ❑ Other(explain under 7g)
Non-Water Supply Well: IttbpflilWien ProCS9C°d)�usk
❑Monitoring ❑Recovery 7E For each materiM 1e' rk4)Qove,provide amount of materials used:
Injection Well:
❑Aquifer Recharge roundwater Remediation 7
f j
❑Aquifer Storage and Recovery Salinity Barrier I Q .b&g 3(�w
f1t ( irI
❑Aquifer Test ❑Stormwater Drainage G
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment prof edure:
❑Geothermal(Closed Loop) ❑Tracer S L� t)JArej 3/y �]Zvi hl6'�
❑Geothermal(Heating/Cooling Return) Kr 1.❑O•ther(explain under 7g) O�K et
p L �U fir r �!L (.'/G1 R /rh
4.Date well(s)abandoned: J t.C_ �
5a.well location:
d\ J ®f1 8.Certific on:
Facility/Own er Na a Facility 1Dtl(ifapplicable) `
s 1 z�l�(Z3
buca
Sign re of Certified Well Contractor or Well Owner Date
Physirz,
dress,Ci and Zip
I � C "( '1 By signing this form, I hereby certh,that the well(s) was(were)abandoned in
l Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 WeAConslruction 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 lattiong is sufficient) You may use the back of this page to provide additional well site details or well
`f' I,b 1(d;f ` ! _N Is If a I .� W abando ment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING_ABANDONED SUBMITTAL INSTRUCTIONS
Attach well corutraction record(s)rf avmlable. For muhrpl�injection or non water supply
wells ONLY with the some construction/abandonment,you can.subrnir one foray. 10a. For All Wells: Submit this form within 30 days of completion of well
e�nk_ ��a� abandonment to the following:
69.Well ID#:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699-1617
6b.Total well depth: ` (ft.)
]Ob.For Infection Wells: In addition to sending the form tothe address in 10a
�l��ri� above,also submit one copy of this form within 30 days ofcompletion of well
6c.Borehole diameter• (in.) abandonment to the following:
c� Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface .J ' (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
6e.Outer casing length(if known): V
��`{,1t Qum 10c. For Water SuuaI &Infection Wells: In addition to sending the form to
the(ft.) n 30 days of
compl (etion of we &ndonment o!the county health department
above submit
of he county
where abandoned.
6E Inner casing/tubing length(if known): ~ (ft.)
6g.Screen length(if known):
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Form GW-30