Wake_Well Abandonment_20240731 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J'd h L.b� 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
IA wells abandoned:' OAF.,
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a Pbb L e- ( L[/, FOR WATER SUPPLY WELLS ONLY: o
Company Name 1 1 h}-
O ��w �O�� 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits 0.e.UIC,County,State,6artanee,etc.)ijbtown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Suppiv Well: 7e.Sealine materials used(check all that apt►v):
❑Agricultural ❑�Ilunicipal/Public ❑Neat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
C1lrri ation 1 ❑ Specialty Grout ❑ Gravel
Non-Water Suppy eh: q.:' ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring Recovery
Injection Well: _ 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge Wr6vtifdwater Remediation S I GtG S 2 �` S
❑Aquifer Storage a08m'*e f. s ❑Salinity Barrier —LL'„�
❑Aquifer Test ❑Stormwater Drainage h�
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer 7g,provide a brief description of the abandonment procedure:
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❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) �rQV T--�F--
4.Date well(s)abandoned:
Sa.Well location:
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Facility/Owner Name Facility TD#(if applicable) 8.Certification:
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Physical Address,City,andlZip Sigrifre of Certified Well Contractor or ell Owner Date
,NI Q lc,e, 4,4 4115 I By 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 217.0200 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:
(if well field,one Wong 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 WELL61 BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the.same construction'abandonment,you can submit one form. 10a. For All Wel(sAll Wells: Submit this form within 30 days of completion of well
60 WAI tnfi, abandonment to the following:
Division of Water Resources,Information Processing knit,
6b.Total well depth:_ _ _ _(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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): 11 LA (ft.) iuc.rur water ziuuuty ac tuiecuon wens: to auuwoo lu senumg ule tutor 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.)
Form CTW-30 North Carolina Department of Environmental Oualitv-Division of Water Resources Revised 2-22-2016