Davidson_Well Abandonment_20240205

1.Well tractoor In or ation: rA^ WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or ClosedlLoop Geothermal Wells having the same
Well Contractor Name(or well ovmer personally abandoning well on his/her property) well construction./depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:+
l.�
NC Well Contractor Certification Number 1�' 7b.Approximate volume of wateri remaining in well IS): (gal.)
Morgan Well & P u mp,p I N C FOR WATER SUPPLY WELLS 10NLY:
Company Name anulated chlorine
7c.Type of disinfectant used: g ;r
2.Well Construction Permit#:
List all applicable well constuction permits rLe.UIC,County,State,Variance,etc.)if known D
• 7d.Amount of disinfectant used:'
3.Well use(checkwell use):
Water Suppbr Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) *onctete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selted above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwatet Remediation !S
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Pr a brief descr' tion of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ' ^ ^
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) -CJ r^.6 ho d'I< 0
4.Date well(s)abandoned: Q �^ 2-9 LAJ 't�� 1 �� r 6. C �1 6�1�c_ 7)S o,A
5a.Well location: 1 i�'L_�
Facility/Owner Name Facility M#(if applicable) 8.Certification:
(83z )Vn [-Zz-zQ
PhysicallAddre City,and Zip Signature of Certified Well Contractor or Well Owner Date
Owi Ns !/ `� By signing this forrn, I hereby certo that the wells) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0.100 or 2C.0200 Well Construction Standards
and that a copy of this record has bee'n provided to the well owner.
5b.Latitude and longitude in•degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N W 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 records)1favailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: a— �—ab:donment to the following: i
AJJ
A Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) C� 5 2024 1617 Mail Service Center,Raleigh,NC 27699-1617
�J o.-,rr :. WArdx Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: ZC) (in.) 1n+arsro."y ' ' r1. above, also submit one copy of this iform within 30 days of completion of well
D`� k.''" abandonment to the following: ;
I;
f 6d.Water level below ground surface: Division of Water Resources,Underground Injection Control Program,
1�-1' (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (gt) 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 countq health department of the county where
6f.Inner casing/tubing length(if known): / V�(ft.) abandoned.
6g.Screen Iength(if known): _ 1 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources (' Revised 2-22-2016