Union_Well Abandonment_20240910

WELL ABANDONMENT RECORD ForintcrnalUscONLY:
1.}'f, contractor Information: ABANDO
l,� WELL NMENT DETAIL'S
_ �/ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contrictor Name(or well owner perdZnjy abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well
Contractor Certification Number I ,n�+ 7b.Approximate volume of water remaining in well(s):_ (gal.)
Y C l.(�11` ,�C� Y 1G1r5 �U ll� FOR WATER SUPPLY WELLS ONLY:
Company Name
I ' 7c.Type of disinfectant used: \:�l OY'I>n
V Q
2.Well Construction Permit#: l ay� CGO -'�
List all applicable ivell construction permits(i.e.UIC,Comity,State,Pm lance,etc.)ifkno vn
7d.Amount of disinfectant used: 0
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check ail that appyl�): ��`' �•• tn�p
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout U/Bentonite Clr Eq Pe,JIVA
❑Geothermal J1
(Heating/Cooling Supply) > esidential Water Supply(single) El Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cytfin asp k t-f Cxt.�„u
r
❑Irri ation ❑ Specialty Grout ❑ Gravel 1
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 so (b .C1h 1P�
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
_`,,J, ��� �L p,,
❑Geothermal(Heating/Cooling Return)
❑Other(explain under 7g) /��C�V`1 U Q���� � c���Q �(T1/_
4.Date well(s)abandoned: JI r u 1 VJ P�� , pd��ea 25- 5o Ib bay O{` �Q1C`�Vtl
Sa.Well location: �` 1�5 • Cly 1�a�\ ���n`` �,t
J MT S RMQ
Facility/Owner Name V Facility IDN(if applicable) 8.Certification:
5211 I
Physical Address,City,and Zip Q 2 1 I Signatu of Certified Well Contractor or,Well Owner Date
r uy lm D L<v J `� L By signing this form, I hereby certi,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 are well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t-1 I,�' 9.Site diagram or additional well!details:
35.0991e$1� N "�V�S W 1� 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 SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For untltiple injection orrtan-watersupply wells
ONLY with the same constnictiat/abandoruuernt,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:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 1 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in IOa
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: 4 D (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
IV�'` (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known):
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):
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

I
WELL ABANDONMENT RECORD For Internal Use ONLY: 4
G
1. eeR Contractor Inf/o�rmation: D WELL ABANDONMENT DETAILS
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:
rT ;
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 3 (gal.)
Morgan well & Pump, Inc. FOR WATER 7a Type of disinfectant used:
SUPPLYWELLSONLY:
I
Company Name ^ a ��Gnc�ad
2.Well Construction Permit#:_
List all applicable well construction permits Ci.e.UIC,County,State,Parlance,etc.)ifknown so Z
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 97-13 ntonite Chips or Pellets _
❑Geothermal(Heating/Cooling Supply) BTlesidential Water Supply(single) ❑ Sand Dement Grout ❑Dry Clay �"j � <,f
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout brill Cuttings
❑hrigation ❑ Specialty Grout ❑ Gravel SEP 1 0 N24
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) a r
1rr�sr '. rl
❑Monitoring ❑Recovery „q�t_ '
Injection Well: 7f.For each material selected above,provide amount of materials'rt�et'
❑Aquifer Recharge ❑Groundwater Remediation w-50 Dr i l l
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage r0 �
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer _GwLJ,5V l 61 10 57e I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Y l
I DON Crh &-tl� 50 ' -ty
4.Date well(s)abandoned: iTA` 1/iC�
'A n
Sa.Well location: J�
rnes
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
66 f!fK
Physical Address,City,and Zip m Signature of Certified Well-Contractor•or Well Owner• Date
By signing this form, I hereby certify that Ae 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.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
0-2 .3? N `0� 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 SUBMITTAL INSTRUCTIONS
Attach well construction records)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
Q 10b.For Injection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: �u (in.) above, also submit one copy of this form within 30 days of completion of well
2 abandonment to the following:
6d.Water level below ground surface: 3o (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (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 known): _(ft.) abandoned.
6g.Screen length(if known): /Y/T (ft.) i
r
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016