Wilkes_Well Abandonment_20240423 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well tractor Information: WELL ABANDONMENT DETAILS
C.i�Le, 79.Number of wells being abandoned:
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Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-warei supply wells ONLY with the sane
construction/abandonment,you can svbntl i one form. —
7b.Approximate volume of water remaining in well(s): t/ (gal.)
NC We 1 oqq for Ce tic ion Nf tuber
FOR WATER SUPPLY WELLS ONLY:
Company Name ` 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable wellpernrits 0.e.Cortn%Stare,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well 7 Sealing materials used(check till that 7,Bentonite
y❑Municipal/PublicNeat Cement Grout Chips or Pellets
❑Agricultural
❑Dry Clay
❑Geothermal(Heatin Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout '• �
❑Industrial/Commercial oResidential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings t{;;ry
❑Irri tion ❑Specialty Grout ❑Gravel APR 2 M4
N n-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) .: .yam j
sr
o ng ❑Recovery 7E For each material selected above,provide amount of materials
Injecttionion Well: _ � ..Qp
❑Aquifer Recharge ❑GroundwaterRemediation Sp lk bfDrt� &t !-t
❑Aquifer Storage and Recovery ❑Salinity Barrier �rCC� t�2 x 46ked len
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g, rovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 0 �
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.J
4.Date well(s)abandoned: 2,12- IUD_►y_T y /�/G/r(/ �'G-� /11 ' tt��`-��Ous"f�11��/1ur.
So.W I location: t✓e-ft e.d (,Qpw, Tk well co; �� � � .bg t7)y � b,�yt;1 r� J t Q 1—
W C� .�t,�t 13 06-0-ooc o I N �.s t,
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Facili # ifa livable 8•Certifica
Facility/Owner Name ( pP �
Physical Addr ss,City,and Zip gna u ofCerti d Well dontractor or Well Owner Date
By signing this form, !hereby certh,that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 lat/long is sufficient) 9.Site diagram or additional well details:
3! o I, , o® 2 N r 7 p f �� Dp You may use the back of this page to provide addition
al well site deils or well
tp l�- 0 -1 y 0 r r W abandonment details: You may also attach additional a es if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For hadaple injection or non-water supply
wells ONLY with the same constnrction/abandoninenr,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!(: r',,rye`W L4
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: �® (ft.)
10b.For Iniection Wells: In addition,to sending the form to the address in 10a
14 above,also submit one copy of thisli form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
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Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: /3d (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c.For Water Supply&Infection) Wells: In addition to sending the form to
6e.Outer casing length(if known): 3 (ft•) the address(es) above, also submit lone copy of this form within 30 days of
completion of well abandonment to fthe county health department of the county
where abandoned.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): is (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013