Rowan_Well Abandonment_20240814

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Tejjfey Fo5ie r 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on Ws/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
^ wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well & Pump, Inc. I,ORWATER SUPPLY WELLS ONLY:
CornpanyName
2.Well Construction Permit M 5 6 —1 7c.Type of disinfectant used: '7i,W/Nt.q� l 1 6A C
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknorwr 0_J�}CJ
7d.Amount of disinfectant used: V'L
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that ap y):
❑Agricultural ❑Vfunicipal/Public ❑ Neat Cement Grout Bentonite Chips or Pellets
00cothennal(Heating/Cooling Supply) Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaUCormnercial ❑Residential Water Supply(shared) Uf Concrete Grout ❑Drill Cuttings
❑Ini ation ❑ Specialty Grout ❑ Gravel
Noll-Water Supply Well: ❑ Bentonite Shiny O Other(explain under 7g) .
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
[]Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ( AUG 1 20?�
❑Geothermal(Heating/Cooling Return) ❑/Other(explain under 7g �(�(�a{��'1' �I^��A�t TAQ .
4.Date well(s)abandoned: kt f
5a.Well location:
GUNe kNe4
Facility/Owner Name Facility IDN(ifapplicable) 8.Certification:
fbaS _
Physical Address,
(City,an(d'Zip Signature of ertified Well Contractor or Well Owner Date
Saf(71?yl T YJ � By signing this form, I hereby certiyy that the well(s) was (were)abandoned in
County Parcel Identification No.(PER) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Const•uction Standards
56.Latitude and longitude in degrees/urinates/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,onnee`latfloonng is sufficient) t y 9.Site diagram or additional well details:
3 Ft N a D.V+#7`*/ 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 WELLfS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(*)ifavailable.For multiple injection or non-water supply wells
ONLY with the same canstructionlabandounrent,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 Mall Service Center,Raleigh,NC 27699-1617
10b.For Iniectien Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: !a. (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): KA (ft.) 10c.For Water Supply&Injection 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(mown): (ft.) abandoned.
6g.Sercen length(if known): 91% (ft,)
Form OW-30 North Carolina Department ofRavironmentol Quality-Division of Water Resources Revised 2-22-2016