Union_Well Abandonment_20240903 (2)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.WellOv,
ractor info mation: WELL ABANDONMENT DETAILS
i Q`j 7a.Number of wells being abandoned: /
Well Contractor Name(or well owner onally abandoning well on his/her property) For multiple injection or non-water o supply wells ONLY with the same
construction''abandnnment,you can submit one form. ^7
Ly'� 7b.Approximate volume of water remaining in well(s):
N Well Contractor Certification Number
r�,Uo-.> � � FOR WATER SUPPLY WELLS ONLY: /�
Company Name r 7c.Type of disinfectant used:_ r4 T r'
2.Well Construction Permit#: C-A LV^ 331
List all applicable well permits(t.e.County,State,iMariance.Injection,etc.)ijknown 7d.Amount of disinfectant used: /
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) ❑�Sandd Cement Grout ❑ Dry Clay
❑industrial/Commercial DResidential Water Supply(shared) 'n �-o"crete Grout ❑Drill Cuttings
Ohri ation ❑ 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
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the aband nment procedure:
OGeothermal(Closed Loop) ❑Tracer �-•
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
F'YCay.z`.,C.
4.Date well(s)abandoned:
i
5a.Well location:
Facility/Owner Name Facility ID#(ifapplicable) g•Certify
Physical Address,City,and Zip Signat o eni d Well Contractor or Well Owner Date
✓�/p/ By signing this form, I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PiN) accordance with 15A NCAC 02C.0100 or 2C.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 wcl)field,one lat/long is sufficient) 9.Site diagram or additional well details:
3
! �� N �O`�p fvJ W You may use the back of this page
p age to provide additional well site dtails or well 9 i b/ W abandonment details. You may also attach additional pages if necessary.
_CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)f available. For multiple h jeclion or non-water supply
wells ONLY with the same consintcriotruhandonment,you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
/ abandonment to the following:
Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
66.Total well depth: � (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter; 2, (►n•) abandonment to the following:
0 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: ! (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
lOc. For Water Suaaly& Iniection Wells: in addition to sending the form to
6e.Outer casing length(if known): n' (ft) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): Y (ft)
Forth GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Aninm 9011