Orange_Well Abandonment_20241014

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor I/nformation::? J WELL ABANDONMENT DETAILS
�U 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
/ 0i n wells abandoned:
NC�Well`Contractor Certification Number 7b.Approximate volume of water iemaining in well(s): �—I (gal.)
►`-el FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:J3 1—R
2.Well Construction Permit#: ,y ItL1' — ccr
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 41n 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used,(checkall that apply):
❑Agricultural ❑Municipal/Public ❑Neat Ce.16wrqut_ _ ' n ' :.,. ., 0 Bentorute Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EkIk4idential Water Supply(single) ❑Sand Cement Grout1 ❑Dry Clay
❑htdustrial(Commercial OResidential Water Supply(shared) El Concrete Groot T 1 2024 Cl Drill Cuttings
1:11trigation ❑ Sped a)ltty rQpt.;_ Gravel
"
Non-Water Supply Well: " ".' r"• "``}3
� ❑Bentonite Slurry�i i Other(explain under 7g)
❑Monitoring Bifecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier V��L
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Retum) ❑Other explain under 7g) V 0 J-�V A
0�002 ,a. �Gx.✓1-' 1%� b/YL �'o e (bwWlcr
4.Date well(s)abandoned: �o���. �' ! e_ _rl _ __ 11.,
5a..Well location:
FaeilitylOs nerName r Facility JD#(if applicable) 8.At "
Ceerttification:
q q!�64� fthr 5
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County L001 Parcel Identification No.(PIN) accordance with 15.4 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 well field,one lat/iong 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit oneform.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
r Division of Water Resources,Information Processing Unit,
6b.Total well depth: to`� (ft.) 1617 Mail Service Center,Raleigb,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.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,iUuderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): G (ft.) 10c.For Water Supply&Iniection'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
6E Inner casing/tubing length(If known): (fL) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

l \
\
t
J�
r \