Alamance_Well Abandonment_20240610

WELL ABANDONMENT -
For Internal Use ONLY:
1.Well Contractor information.. RECORD
Jamie Neugent WELL AB Use
Well Contractor Nama(or well owner personally abandoning well on his/her property) 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
P ��) well construction/depth only 1 W.-300 is needed, Indicate TOTAL NUMBER of
2677- (:�:,
wells abandoned: _
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
AquaDrill Inc.
Company Name FOR WATER SUPPLY WEL1,S ONLY: r
L Well Construction Permit#:�O✓�L(�✓7 lc.Type of disinfectant used:
List all applicable well construction permas((a f17C,Cos
M"Stale,Variance,e1V.)iflrnown
3.Well use(check well use): 7d.Amount of disinfectant used:
Water Supply Well; —
❑Agticultutal 7e.Sealing materials used(cl eck all that apply):
;dcouicipal/Public pp y)'
❑Geothermal ❑Neat Ce,ncttt Grout ❑Bentonite Chips or Pellets
(Heating/Cooling Supply) al Water Supply(single) ❑Sand Cement Grout❑Industrial/Commercial ❑Residential Water Supply(shared) JKC ❑Dry Clay
❑hri ation yr Concrete Grout ❑Drill Cuttings
Noo-Water Supply Well; 1 ❑Specialty Grout ❑Gravel
(]Monitoring ❑Bentonitc Slurry
❑Recovery El Other(explain under 7g)
Injection Well:
❑Aquifer Rech ❑ materials used:
arge 7E For each material selected above,provide amount of materi Groundwater Remediation ✓ r,,'„
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control --
RN
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment Ppnt epa f"u
Geothermal(Hearin Coolin Rettun) ❑Outer(explain under 7
> �'C s:��c1-�iC�.h •��w 4�.�i Fez� .s�r,�dL(�
4.Date well(s)abandoned:
Sa.Well location:
FambtylOwmr Name Facility ID#(if applicable) 8.Certification:
�15 Asti<a %
PhysIcal Addrety,and Zip '/� {�
/Z ss,City, gtii ofC a Con aror\Veil owner
IJate�J���y��
County By signing this fonn, 1 hereby eerty y that the well(s)
("'ere)was
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well ConsiructionaStm abandoned
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the welt owner
(if wcu held,onc(among is sufricicnt)
�, 9.Site diagram or additional well d�:tails:
N � T i42 7 Z9.ay���r�� 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 if necessary.
CONSTRUCTION DETAILS OF WELLi Q1 BEING ABwNDOyED
rfavailable.Formultipleinjectionornan-watersupplykells SUBMITTALLNMuCTIONS
Armchwcllcunstnmdonrewrd(s)
ONLY with the.same construction/abandanment,yan can.submit oneform
6a.Wen ID#: 102. For All Wells: Submit this filrm within 30 days of completion of well
abandonment to the following:
6b.Total well depth: Division of Water Resources,Information Processing Unit,
(R- -) 1617 Mail Service Cen ter,Raleigh,NC 27699-1617
6c Borehole diameter.
7 10b-For Infection Wells: In addition to sending the form to the address in 10a
_ (in.) above also submit one copy of this ibnn within 30 days of completion of well
<�
abandonment to the following:
6d.Water level below ground surface: ) (�) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (�) 10c-For Water Suooly$IZi ecdon VNells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well 6f.Inner easing/tubing length(if known): R-� abandoned abandonment to the county ht,alth department of the county where
6g.Screen length(if(mown): Y i� (It.)
Form GW-30 North Carolina nenarrment