Haywood_Well Abandonment_20240119

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.W/ell tractor Information: WELL ABANDONMENT DETAILS
' b� 7a.For Geoprobe/DPT or Clol Closed-Loop Geothermal Wells having the same
well ctor Name(or wel owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed`Indicate TOTAL NUMBER of
wells abandoned:
4 A- I NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): .GJ (gaL}
Wl Y� W 1
FOR WATER SUPPLY WELLS ONLY:
Company Name 1
n 7�Type of disinfectant used>
2.Well Construction Permit#: f I`J�
List all applicable well construction permits(i.e.61C,County,State,Variance,etc.)iifknown I Dot
7d.Amount of disinfectant used:
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mu�nicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑Sent Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) crete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: Bentomte SJutry ❑Oth __ _� eL(explainirrtder_7g)—
❑Monitoring ❑Recovery
Injection well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4-Inns JI i)�
❑Aquifer Storage and Recovery []Salinity Barrier❑Aquifer Test ❑StormwaterDrainage A, Co a //+� Q
!w l�il)
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment proc dure:
❑Geothermal(Closed Loop) []Tracer . J
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) AA 0
4.Date wells)abandoned:
Sa.Well location: y 2024
8.Cc rtitica l r i`^n i
Facility/Owner Nam y Facility ID#(if applicable) J;y �aE' ] C;r
Physic 1 Address,City,and Zi Signs of red ell Contmc or Well Owner Date
I.
`ry I i0 ✓t a— By signing this form,I hereby certify that the wells)was(were)abandoned in
Co my Parcel Identification No.(PIN) accordance ivith 15A NC4C 020.0100 or 2C.0200 Well Construction Standards
and that a copy of this record Itas'been provided to the ivell owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell11field,one latnong is sufficient) � [�j 9.Site diagram or additional well details:
(j
N 7C /ED - You may use the back of this'page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary:
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupply wells
ONLYwith the�y»e canstrpctl abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# �2M� abandonment to the following:;
i Division of Water Resources,Information Processing Unit,
6b_Total well depth- (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617
1 10b.For Iniection Wells: hi;addition to sending the form to the address in 10a
6c.Borehole diameter: I (in,) above, also submit one copy of,this form within 30 days of completion of well
abandonment to the following'
I
6d.Water level below ground surface- �3 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): b (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to 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
6f.Inner casiog/tubing length(if known): (ft•) abandoned.
6g.Screen length(if known): r (ft_)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016