Rowan_Well Abandonment_20240710

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well/Contractor Information:
WELL ABANDONMENT DETAILS
CACAM� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
690 - A-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name '
-- :_ --ons - eon= er-mz- —- - - - -- — - -- — - ---
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknown 36 Z
7d.Amount of disinfectant used: I.JV
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout BBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Bfesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) .
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ��5
❑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 n�1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: b q
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Sa.Well location: Uri-
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Facility/Owner Name Facility ID#(if applicable) 8.Certify lion:
36 c-u0 I2A)CUA,w C RC IIS (� •'�3,,t
Physical Address,City,and Zip
—I Signature c Certified Well Contractor or Well Owner Date
N ` L;�H o1 By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 lat/long is sufficient) 9.Site diagram or additional well details:
/ 51a �Q '3 Q d W You may use the back of this page to provide additional well site details or well
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abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the some constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well M#: abandonment to the following:
uDivision of Water Resources,Information Processing Unit,
6b.Total well depth: + (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
n 10b.For Injection 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): N (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this foam within 30 days of completion
A of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): 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