Franklin_Well Abandonment_20240529 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.iM�!�
ntractor Information:/� WELL ABANDONMENT DETAILS
�m�1'\frJ t'J 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Comrsew Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Gwells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s):
l I"./ GQ f �j FOR WATER SUPPLY WELLS ONLY:
Company Name 14 f 14
7c.Type of d M isintecnt used:
2.Well Construction Permit#: -
List all applicable well construction permits r e.UICS County,State,Variance.etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that aPPIY):
❑Agricultural ❑Municipal/Public `Neat Cement Grout ❑Bentonite oral Cllt•ts
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay r 't 2024
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
DIrrigalion ❑Specialty Grout ®Gravel JT
Non-Water Supply Well: ❑Bentomte Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Sal nity Barrier �//J,,•i���
❑Aquifer Test ❑Stormwater Drainage hk&+ i!.& 'v t g4-0/iJ 3
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal Heafi Cool' Return ❑Other(explain under 7 �� �(/�f f, / J ��✓L �`�
ram% Citn'4' i U Ff h� t..f-
4.Date well(s)abandoned: 11 8—6y H�
5a.Well location:
� � d
F ility� Facility JD#(ifapphcable) S.Certification:
7g 3 qU l HwJ 1 ct,—�D&2q 44�<Ss4� l
Physical Address,City,and Zip Sty oture fCertified Well Contractor or Well Owner Date
�w y y-4` By signing thin form I hereby certify that the well(s)was(were)abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 01C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwetl field,one lat/long is sufficient) 9.Site diagram or additional well details:
1 N, You may use the back of this page to provide additional well site details or well
"1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifamilable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ED#• abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: Mbq ��• (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: (�,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: U (it,) Division of Water Resources,Underground Injection Control Program,
/ 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): t� 1 (ft.) 10c.For Water Supply&Injection Wells: hi addition to sending the form to 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
6f.Inner casing/tubing length(if know n): _(ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016