Warren_Well Abandonment_20240423

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W.ELL,ABANDONMENT RECORD !Iiiur litremali lUizeti11/112.: ill
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WELL ALTANDONNItEITLT if E.rturst
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-.5112aPi IN —IN,' Of t t )) sip rout may,ase the:back GEO-Ifs pagp fir Exaviirc adillitunat wen silt dttairs Or Mail
abandonmeacctrAMIt You troy arso attach additional'pans fr mass:try:
COA-Slint reTtomBE.TAILS 0 IF WEL IL(S),BEING ABANDONED, !
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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAiS '
11I1 p . ftQ/1 S(t':/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Name(or well of persomllyrnbaodomng well on ttis0eerpmpeaty) well constntction/depth,o my 1 GW-30 is needed-In dicate TOTAL NUMBER of
wells abandoned:
3S1I �y
NC well ContrarsorCeni6la�tion Naafi \ ` 7b.Approximate volume of water remaining in wags): -9 (gal,)
�J �N iE�14 W. i1 Tr'1 li Ilia f j1G- . . FOR WATER SUPPLY WELLSONLY I
�J'"1�/1 7c.Type ofdisinfectantused: Lea iekftn, It y'pOe-1110int t le...
2.Well Construction Permit#: l`�ivf— '2-4-3
Liu all applicable rrnll canstruMionperndtr Ire UIC,Calmly;State.Pmiaaer;etc)ijlnoun 7d.Amount ofd-rsinfecmntused: 6 0 ,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): ;
' ❑Agricuimral ❑MunicipallPublic X Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) '$Residential Water Supply(single) 0 Sand Cement Grout ❑Day Clay
❑Indushial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout " t
❑Drill Cuttings •
❑irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry (;
❑Monitoring, ❑Recovery CI (explain under 7g) APR °� r [Ih 24
Injection Well: 71.For each material selected above,provide amount of materiats used:
❑Aquifer Recharge OGmundwat r Rcmcdiatiun �, ^a'ul
OAquifer Storage and Recovery OSalmity Bather Nat f':9 r e/4- <' -t�x �f 11";.G ...1":-.....,..1-' -,
OAquiferTest OStomrwnterDrainage - - '
°Experimental Technology °Subsidence Control
❑Geothermal(Closed Loop) O f 7g.Provide a brief description of the abandonment procedure:
racer
❑G rm (Heating/Cooling(H ating/Cooling Return) °Other(explain under 7g) 1 $419 r 4 zt. IX el
44 ?- -r 11-F-ni4., to ,a i'f P.t`}-v'.Qw,rtt i e
4.Date well(s)abandoned: 014105/aa aif P
4# 3 F i Ilea -1-e p 3 b •ce^. t ck,,,,-q 0 o.^
5a.Well location: 1
boI1q Q Dodo 6-ct T-dY -�• � �y,•� rat n �i�f i rrs+-�i t .
Facility/OmeerN Facility IDA fifappli©blc) 8. - cation:
113 t—e/1Gicr^reef r4'1111ACoil ArG .Z-75-SI I
Physical Address.City,and.rip Suet of Beal Well C tractor orW Owner Datcf`o S/.2(2s+
Wacr'e.t1 ;'.• c
Ily signing thus fain,1 hereby wilt'.that the well(s)was(were)abandoned in
County, : ""Parcel[dentifiation No-(PIN)' accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb Latitude and longitude and that a copy of this record has been provided to theusd1 owner.Ip degrees/minutes/seconds or decimal degrees:
.(ifwell field one Wong is Suffield*
_ 9_Site diagram or additional well details:
-3 ` t?l 0 6.3-0I N 7 S.L. OC- eE 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 ifne ty_• •'.r
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach itch!consnactionreeonl(s)rfarnilabkeForawhip(a injection ornva-watersopplytJfr SUBMITTAL INSTRUCTIONS: - •• ... .-. •
ONLY trith the same t'oaurmylonfabandanmenl,you can submit one fork
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10a.For MI Wells: Submit this form within 30.days,of completion of well
6a.Well ID#: Et)P-ALL--'%( - abandonment to the following-
I Division of Water Resources,Information Processing Unit,
6b.Total well depth: i S ( ) . , . - .1617 Mail Service Center,Raleigh,NC 27699-1617
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10b_For injection Well= In addition to sending the than to the address in 10a
6c.Borehole diameter: . -67g (-I) ahoy;also submit one copy of this form within 30 days,of completion of well
;;r;• . abandonment to the following -
6d.Water level below ground surface: ' a (ft) Division of Water Resources,Underground injection Control Program,
. • 1636 Mail Service Center,Raleigh,NC 27699-1636
6,Outer casing length(if known): , 'Li-vZ> (R.) 10c.For Water Su_pals&Infection Wells: In addition to sending the four to the
u:• _ addrrss(cs)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
6E Inner casing/tubing length of known): /k//4 . _. -(.)- - . -_ abandoned...:. r - . •
6g.Screen length(if larowm)1 ' /s!1 A• ( .
Form GW-30 1+Ja
__ North Caor®
IAep;utromtofF.avironmmtalQmldy DiwiswoofWattrResotmu
- _ Revioed2-22-2at6