Durham_Well Abandonment_20241022

WELL ABANDONMENT RECORD For Internal Use ONLY: •
1.Well Contractor Information: WELL ABANDONMENT DETAILS
1 I lC c 114.N.N: — ._ 7v.For Geopmbe/DPT or Closled-Loop Geothermal Wells having the same
well Contractor (dr owner personally abandoning well on his/he property)4 well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
��to "{., wells abandoned:
i •
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
U)ety COrap , e.E 1 j �1.�.,. FOR WATER SUPPLY WELLS ONLY: ._ _ -
4..
Company`�N \\ '
7c.Type of disinfectant used: • ' 1
2.Well Construction tion Permit#: 1
List all applicable well constructionpennits(Le UIC.County,State.Yada►ng eta)ifknown8 7d.Amotmt of disinfectant used: ocs e
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply,_):
°Agricultural • CMunicipal/Public 0 Neat Cement Grout tonite Chips or Pellets
° al(Heating/Cooling Supply) °Residential Water Supply(single) *fend Cement Grouta7.Rig t;,.,,,1,N;14,') :Dry Clay
Commercial °Residential Water Supply(shared) 0 Concrete Grout ❑Din'Cuttings-- - -" - -- —
°Irrigation 0 SpecialtyGroaf OCT u 2 LOHGravel
Non-Water Supply Well: ❑Bentonite Slurry le er(explain under 7g)
°Monitoring °Recovery It„o:;�z,c: ��:v- ,JnI
:?f.For 1'acltanaterial selectei)rala *ii lde_amount of materials used:
Injection Well:
°Aquifer Recharge °Groundwater Remediation i,,,
°Aquifer Storage and Recovery °Salinity Barrier Y = _ + _
°Aquifer Test oStonuwater Drainage �� y► f �-.a 11`:Al& % �- I s_
°Experimental Technology °Subsidence Control v °ir C1 \ tic` eSe4 5 Y�, -
7g ' , , a bri• pima,brure a,•° i moment proceuurreo
°Geothermal(Closed Loop) °Tracer LiteF1 �I' -74
°Geothermal(Heating/Cooling Return) °Other(explain under 7g) " Cp "fez•�P 1 I. . 7-'un� n
A- 0 111- -tom A' U 17136. - -
4.Date well(s)abandoned: 0 — L, h i 4 A6 e ram,) - Di
Sa.Well locatlore
VA
'VI CIA0k\e—crtjtAtkilMINci CotVe0.— " C .
Vacility/Ownegime P&I ilitylDt(if appli le) R.Certificati :
3 CCX) K)UkVice_\--\nriVc- 6, lac •
Physical Address,City,and Zip Sii of Certified W 1 Co °ctor or well Owner IDa
jl-"l I
c)u t4CA
By signing this form,I hereby'certify that the wells)was(were)abandoned in
County Parcel IdentificationNo.(PIN) accordance with 15ANCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sit.Latitude and longitude in de greeslndnuteslseconds or decimal_degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
S 7 7 O N *78'91 `(,(04 W You may use the back of ibis page to provide additional well site details or well
YY�� abandonment details. You may also attach additional pages if necessary.
• CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifavailabla Formultiple injectionornon-watersupply wells I
ONLY With the same construction/abandonment you can subunit one fonrc 10a.roar All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
vlslonof Water Resources,Information Processing Unit,.
!fir
6b Total well de /'DS (ft.) r 1617 Marl Service Center;Raleigh,NC 276991617
• 10k Foriniection Wells: In addition to sending the form to-the address in l0a
•• 6c.Borehole diameter. (m) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: /4 (ft.) Division of Water Resort'ees,Underground Injection Control Program,
�11 1636 Mall Service Center,Raleigh,NC 27699-1636
6e.Outer t'V length(if known). 4 (ft.) 10c.For Water Supply&Service,
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
6&Inner casing/tubing length(if known): 4 (ft.) abandoned.
6g.Screen length(if known): 4fr (ft) -