Wake_Well Abandonment_20240306 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
C�(10,
7a.Number of wells being abandoned:
Well Contpersonally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
rnnsvnuctraWabandomnent,you can submit one form.
7b.Approximate volume of water remaining in wdl(s): (gal)
NC Well Contractor Ce ifioation Number A
A fi CWiL 5C v� FOR WATER SUPPLY WELLS ONLY:NetCompany Name J 7c.Type of disinfectant used:
2.Well Construction Permit#: A1�
List all applicable well pernrtrs(i.e.Coum etc.)if y,Stare,Variance,lnfectian, t^0 7d.Amount of disinfectant used• {i
3.Well use(check well use):
Water Supply Well:
7e.Sealing materials used(cheek all that apply):
❑Agricultural OMunicipal/Public Neat Cement GroutBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) O Sand Cement Grout , E7:DIy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Concrete Grout �"f VII Cuttings
01rrigation ❑ Specialty Grout MAR G 2024❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery In 7,Ta:i,-.i ;;r ; fy
7f.For each material selet vey(proJitk amount of materials used:
Injection Well:
❑Aquifer Recharge G (.�
)(Groundwater Remediation ZS 1 bs l)Jt'►�Lrit�-� �,ty� f—/`j ��``"'Cl��°� -vol(7
❑Aquifer Storage and Recovery ❑Salinity Barrier J) w,, ,,
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control �_91,5afk4e_,Pture.�
Provide a brief description of the aband"o�nment procedure: //J
❑Geothermal(Closed Loop) ❑Tracer 1j �1 t/U Aw'o- fl Z, pie /xel❑Geothermal(Heating/Coolin Return) ❑Other(explain under 7g) n '
/ �,,,INN✓
4.Date well(s)abandoned: . 1-2-31Z Cr�J/ . fi- 6e�nl C �ier kie- pt,!e IYtFs1 c*,,;* a NN
5a.Well location: S�an6 ( Oiltm
Copalut r„F, wel l A[tJAI )
r
��t
PJ
Fa lity/Owner ame Facility""(fapplicable) \
P tysical Address,City,and Zip ^ I St m of Certifi Well Contractor or Well Owner Due
� (� 1 U d Ll, l.� 4 By signing this form, /hereby certh,that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
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:
(ifwell field,one lavlong is sufficient) 9.Site diagram or additional well details:
3�t _-�(� ,t I'�}t You may use the back of this page to provide additional well site details or well
t
1 N '- 'T {: T J 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 non-water supply
wells ONLY with the same constnrcrion/abandonment,you can.submit one form. IOa. For All Wells: Submit this form within 30 days of completion of well
`•/ abandonment to the following:
6a.Well ID#: J y
I Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 5 (ft.)
U l0b. For Injection Wells: In addition to sending the form to the address in 10a
Rabove,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: J (in•) abandonment to the following:
DRYDivision of Wafer Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
Uri 1 l0c. For Water Supply& Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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.
6f.Inner casing/tubing length(if known): vnkhw\ (it•)
6g.Screen length(if known): y,,VkflV'WA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013