Haywood_Well Abandonment_20240301

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For Internal Use ONLY:
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_�. 1.Weill.47tractofrr Information:i� WELL ABANDONMENT DETAILS
f l ut 7a.For Geoprobe/DPT or CI I Fed-Loop Geothermal Wells having the same
wettpctorName(or well owner personally abandoning well on blather property) well constnlctionldepth,only 1 G1N 30 is ceded Indicate TOTAL NUMBER of
, 1{1 wells abandoned
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): �J 9 (gal.)
cka. ukAa4a (flat Pill) 1A FOR WATER SUPPLY WELLS ONL :
Company-name 2.Well Construction Permit#: Pia,
6,,ti•
7e.Type of disinfectant IIsed:1 t )i:11 �/ ru_ i
List all applicable well construction permits(i.e.U(C,County,State.Variance.etc.)Prawn I, 0 O`.
7d.Amount of disinfectant used: L+
3.Well use(check well use): 1
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ❑Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) [residential Water Supply(single) 0 Sand C ent Gro
} ; • 0 Dry Clay
❑lndustriai/Commercial ❑Residential Water Supply(shared) Crete Grout @ % • ( + 0' cgs
Obligation 0 Specialty Grout ct
Non-Water Supply Well: 0 Bentonite Slurry MAN 0 1 20 ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each mafcii l seiigt"ed alSoyelp ' bbmount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation r � '�PI
(=a
❑Aquifer Storage and Recovery OSalinity Barrier ''l�)4'`� l�` 1' {' i i f1 Il
• ❑Aquifer Test ❑StormwaterDrainage - C'e-)(� C ` V ; ( [ i2.J
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1❑Experimental Technology ❑Subsidence Control 7g.Provide a brief 0,,,,,,description the abandonment proc dure:
❑Geothermal(Closed Loop) ❑Tracer . �''
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1/� f-'r1,' Fte.(?ti T('}
4.Date well(s)abandoned: ) +�
,.
5a.Well location:
MI 4 n-A 1 1!'t4villi i 1V
Facility/Owner Nam& t Facility IDd(if applicable) 8.Cerhflca
1pil_tu.v1 pR;a Civrio n c 2t-hri, //Jd( ' - , - '-2G2t'
Physi 1 Address,City,and " Si of ed Well Contra or Well O' er Date
(,��R i I ( {�
"f �lU' l5 '1� ! �,' By sighing this form,1 her'ebyicettify that well(s)was(were)abandoned in -
Co�.nty Parcel Identification No.(PIN) accordance with 1SANCACO2C.0100or fC.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been prootded to the well owner
(ifwell field,one tat/long is s cient) 9.Site diagram or additional well details: .
M'O 141 r f fC i i Ci? N D- t' L l 31 -b I W You may use the back of this page to provrde additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED su an-rAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection Oman-water supply wells
ONLY with the fore co cL abandonment,you can submit one form.
u2tM 10a. For All Wells: Submit:this form "thin 30 days of completion of well
6a.Well IN: ]7'�e-1'n�.It2D�d A- abandonment to the following:
i Division of Water Resources,Information Processing Unit,
Gb_Total well depth: (fL) 1617 Mail Service Center,RaI leigh,NC 27699-1617
t( 10b.For Injection Wells: In addition to lending the form to the address in 10a
Ge.Borehole diameter: (in.) above,also submit one copy of this form}}}���rrr-thin 30 days of completion of well
abandonment to the following: I I
6d.Water level below ground surface: a 3 i (ft) Division of Water Resourc is Vndergr ound Injection Control Program,
r 1636 Mail Servi fe Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): . -l 1' (f-) 10c.For Water Supply&Inje"ction Wells In addition to sending the form to the
address(es)above,also submit one copy of ' form within 30 days of completion
of well abandonment to the county h th department of the county where
n a,
6E Inner casing/tubing length(if known): (ft) abandoned.
6g.Screen length(if known): \ VI' (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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