Anson_Well Abandonment_20240212 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY-
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
7a.Number ofwells being abandoned:
Well Contractor Name(onvell owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): d (gaL)
NC Well Contractor Certification Number aye
�.�. I' LC l k'S LtJ 2 r`� �//'t«l/�9� Z/�G FOR WATER SUPPLY WELLS ONLY:
Company Name / 7c.Type of disinfectant used: ��
2.Well Construction Permit#: �
List all applicable well permits(t.e_Coun(,State,Variance,Injection,eta)if lmown 7d.Amount of disinfectant used:
3.Well use(cheekwell use):
Water Supply Well: 7e.Sealing materials used(check affthat apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 21(esidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) da concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
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❑Monitoring ❑Recovery
Injection Well 7f.For each material selected above;provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation vd t am n C n t:
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer //,) � � 3
❑Geothermal(Heating/Cooliug Retum) ❑Other(explain under 7g) u at
4.Date well(s)abandoned: `a — M/_23 CmYt cr e �rt/S /SiCI•e --rt;=/
5a.Well location:
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S.Certification:
Facility/OwerName Facility ID# rfapPlicable)
Physical Address,City,and Zip S a f C ed Well Contractor or Well Owner Date
&y(jd,©U Gl-s+�i Q �By signing this form,I hereby certrfy that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100'or 2C.0200 Well Constntction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude to degreeslminmes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
/� p ty You may use the back of this page to provide additional well site details or well
3-/I (� 5 /o� Q l N O o., 3 o D 5 1 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or nowirater supply i
wells ONLY with llu;same cmrstructimr/abandonment,you can submit one form. 10a. For All Wells• Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#: i
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617
6b.Total well depth: 3 P Q (fk)
10b.For Iniection Wells: In 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: (im.) abandonment to the following: i
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (110 1636 Mail Service Center,Raleigh,NC 276994636
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10c.For Water Suddly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) the address(es) above, also submit'one w of this form within 30 days of
completion of well abandonment to the oun�" e wanly
where abandoned. 4 � f %+.d
6f.Inner casing/tubing length(if known): 0 (ft)
FEB 12 2024
6g.Screen length(if known): 19 00 #tOlfliAuen Precafoirj uns
DWOMOG
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013