Columbus_Well Abandonment_20231228 (17)

WELL ABANDONMENT RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS
I.Well Contractor Information-
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Ct�W fn.
{- fl 7a.Number of wells being abandon)d:
r' For multlple injection or non-wafer supply wells ONLY with the same
Well Contractor Nam(or well owner personally abandoning well on his/her property) conrtnrction'abondonment•you can submit,or, form.133q
7b.Approximate volume of water r•,emaining in well(s):
NC Well Contactor Ce 5c tson rpber
{ ��'(i 5 s Q� FOR WATER SUPPLY WELLS ONLY: `
Company Name 7c.Type of disinfectant used: 11VJ
2.Well Construction Permit#: I
List all applicable well permits(i.e.Cmmry,Slate,variance,injection,etc.)if known 7d.Amount of disinfectant used
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3.Well use(check well use): 7e.Sealing materials used(check all that a ly)-
Water Supply Well: ❑Neat Cement Gfeut.-.• entonite Chips or Pellets
❑Agricultural ❑Municipal/Public / '`, Clay
(single) ❑ Sand Cement Groh t �.,i /
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ❑ Concrete Grout rill Cuttings
❑industrial/Commercial Residential Water Supply(shared) O E L 2 S 2O ❑ Gravel
❑ Specialty Grout 4 23
❑Irri ation „ ❑ Other(explain under 7g)
Non-Water Supply Well: p Bentonite S IRNf ,•r•D Proca
❑Monitoring ❑Recovery 7f.For each material se)?cW a �i V provide eaamount of materials used:
Injection Well: / ��
❑Aquifer Recharge oundwater Remediation t I e, r�
1L hSt v M1n�
❑Aquifer Storage arid Recovery Ealinity Barrier 3
❑Aquifer Test ❑Stormwater Drainage
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❑Subsidence Control 7 Provides brief description of the abandonment proce ire: �p
❑Experimental Technology g , N / _ J 1'41 e y
❑Geothermal(Closed Loop) ❑Tracer Vr te— (J�j77`�1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) l��gl pJf- (,l�el J i . w Lo ,
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4.Date well(s)abandoned: '
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52.Well oca on:
0VI cc- Oh 8.Certift t' n: �j
Facility/OwnerNa Fa ilitylDN ifapplifla�le) !� L 2-1
E UW JAI, EUI1 1 �����/ l�• L
I Si of Certifi ell Contractor or Well Owner Date
PlsysicvAdJ;ss,�CsV,and ZsPc5 �1� By signing this jornt, 1 hereby certify that the well(s) was(lucre)abandoned in
/U Parce Identification No.(PIN) accordance with I5A NCAC 01C.0100 or 2C.0100 Well 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: y Site diagram or additions[well details:
(ifwell field,onelat/long is sufficient) t you may use the back of this page to provide additional well site details or well
—3-T To f•tl "[ ,' o N 1 d t W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructlon record(s)if available. For ntulliple injection or non neater supply
wells ONLY with the satpe eonstruction/abandontnent,you con submit one form. loa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6s.Well ID#: J �(J
Division of Water Resources,Information Processing Unit,
1 1617 Mail Service Center,Raleigh,NC.27699.1617
fib.Total well depth: + (it.)
lob. For Iniection Wells: ]n 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 v�n✓b`n D wl (in.) abandonment to the following:
f / Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 1 /f (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
loc.For Water Suaaly&Iniection Wells: In addition to sending the form to
fie.Outer casing length(if known):
C .©LL (fi.) 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.
611 Inner casing/tubing length(if known):
6g.Screen length(if known): L r" 4du'M (it')
Form GW-30 North Carolina Department of Environment and Nat Resources—Division of Water Resources Revised August 2013
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