Wake_Well Abandonment_20240306 (4)

WELL ABANDONMENT RECORD FForIntemaf Use ONLY:
This form can be used for single or multiple wells
1.Well 0,n'rsror(",,
t forms WELL ABANDONMENT DETAILS
�' I
7a.Number of wells being a ba ndoned:
WellContrac well owner personally abandoning well on his/her property) For multiple Injection or non-wafer supply welts ONLY with the same
constnection'abondonment,you can submit one form.
3331 7b.Approximate volume of water remaining in well(s):
K7Y-kL" L_A.5,5v(,
Willtion Num
FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: )
List oil applicable well permits(i.e.Cminty,State,Variance,injection,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that Apply).
Water Supply Well: monite Chi sor Pellets
❑Agricultural P
❑Munici al/Public Neat Cement Gro�ti(�` 'y, � P
Dry Cla D and Cement Grout p y
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ S !!�� �
❑Residential Water Su shared ❑Concrete Grout MAR V b 20Z4 ❑ Drill Cuttings
❑Industrial/Commercial PP1Y(shared) t.rcavel
❑ Specialty Grout *�
❑lrrl lion v'ilY'7i1F'l f� t~'
Non-Water Supply Well:
❑ Bentonite SItiAi Other(explain under 7g)
❑Monitoring ❑Recovery
7f.For each material selected above,provide amount of materials used:
Injection Well: f, ,p L (b_JI,
❑Aquifer Recharge _❑ iroundwater Remediation '2S �WS, 1)Lz� ►1� I�S
❑Aquifer Storage and Recovery linity Barrier
❑Aquifer Test ❑Stormwater Drainage N` + a f)6t
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Ss ��p=l ` ,C/ 4lydt An 14-e
❑Geothermal(Heating/Cooling Rehm) ❑Other(explain under 7g)
( Ntl # /� 2-
4.Date well(s)abandoned: � � SII� r'- L's✓�>' nE� cepi' k v1ik,, '" 2-4 Psi
5s.Well location: Sfiahcj C�p COy%-pa►v u
0 c(.Wt 00-0-0000005ggq
acility 1D#(ifapplicable) S.Certff tion:
Faci /Owner Name
q -L Mlle &__WehJet/. All L.
Phys•al d ess,City,and Zip St ure of Certified Well Contractor or Well Owner Date�� I_JU al-4-1 (I U y By signing this fornt, 1 hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 01C.0100 or 1C.0100 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: 9.Site diagram or additional well details:
(if-well field,one tattlong is sufficient)
N ��//�� f� You may use the back of this page to provide additional well site details or well
,
_1 a 4 30 ?? 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)tf available. For multiple injection or non-water supply
wells ONLY with the saine construction/abandonment,you can submit one form 10s. For All Wells: Submit this form within 30 days of completion of well
f abandonment to the following:
6a.Well ID#: �-�1
Division of Water Resources,Information Processing Unit,
�J 1 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: J (ft.)
L9 10b.For Infection 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: (in•) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (fl•) 1636 Mail Service Center,Raleigh,NC 27699.1636
,l 10c. For Water Suaoly& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): t/ n O)Z' (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
Jy�h l)"44 where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
1 / r
6g.Screen length(if known):v n kYN o�I' yl (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013