Moore_Well Abandonment_20240610 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well ContractoaV
a on: WELL ABANDONMENT DETAILS
v 1 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nam owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
, C wells abandoned:
NC Well Contractor Cn Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 17 O Z
2.Well Constructiit#:
�/9�6 S 7G Type of disinfectant used:
List all applicable weltion permits(i.e.UIC,County,State,Yariance,etc.)if known C
7d.Amount of disinfectant used:
3.Well use(check ):
E
pply Well: 7e.Sealing materials used(check all that apply):
tural ❑Municipal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
rmal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
al/Commercial ❑Residential Water Supply(shared) oncrete Grout ..•. �. r Drill Cuttings
n ❑ Specialty Grout i" d Gravel
Non-Water Supply Well: ❑ Bentonite Slurry U N 1 0 a24 ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each X*f* 1�4%ft amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7
4.Date wells abandoned: •�.`^ ��� lJ^n ��
5a.Well location: �' `f+��• Y L
JQAM f S 6�P, �-✓
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
_ 2 6 7 /kfL VLw y -705 C 9 S Pri ti�9 s o- -_---.- _
0.5
Physical Address,City,and Zip t
I �� WluntissrtiS ontractor or Well Owner Date
CBy signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one►attlong is sufficient) 9.Site diagram or additional well details:
N 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 WELL(S)BEING ABANDONED g� � INSTRUCTIONS
Attack well construction record(s)ifavailable.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 ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) 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: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known); A/A (ft.) 10c.For Water Suanly&Iniection Wells: 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 abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known):� (ft) abandoned
6g.Screen length(If known): (ft.)
Fnrm GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016