Wake_Well Abandonment_20241115 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Car W A. 45C)t r 7a.Number otwells being abandon ed:
Well Contractor Name(or well owner personally abandoning well on his/her property) For tnuldple injection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
333q
7b.Approximate volume of water remaining in well(s):
NC Well o�`tor r}e�faation Npmber�•��
y/1} orko�i'C FOR WATER SUPPLY WELLS;ONLY:
Company Name ` 7c.Type ofdisinfectant used:
2.Well Construction Permit M
List all applicable wellpermits(i.e.County,Stare,-Variance,Injection,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: X-,It
ing materials used(check all that apply):
❑Agricultural ❑Municipal/Public Cement Grout,_ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement 2�y, N' a O, ry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
OIrrigation ElSpecialty Grout N 0 V 1 2024 ❑ Gravel
-Water Supply Well: ❑Bentonite Slurry El Other(explain under 7g)
onitoring ❑Recovery
ny r,,;.•-._ i�.�
njection Well 7f.For each material selected above;provide amount o aterials used: Z
❑Aquifer Recharge ❑Groundwater Remediation S illy-t
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage D dL �P A
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer p�,�, dCul� ZC' )
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) t" u � ' �(
j Z '�TTI�t'�i olit f�+� lirtlF Scri �t'.� nt [aIG� cfrejt�9
4.Date well()abandoned:
1 �g
, �/tuGE,llotc � d'iPcLf itL'r��an k�'Ole 7t
Sa.Well location:
cat r plot _ l t' 1 4-11 S•i4vee-
Facility/Owner Name Facility ID#(ifapplicable) S.Certi tiohAt
Physical o diW Add City,and Zip Signature of i ed Well oatractor or Well Owner Date
W By signing this form, f hereby certify that the well(s)was(were)abandoned in
County 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:
tfwell field,one fat/long is sufficient) 9.Site diagram or additional well details:
C' Q o You may use the back of this page to provide additional well site details or well
N o J 4 t)aq W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For mtllivie Injection or non-water sappl}•
wells ORLY with the same constructionlabandoninent,you can submit one jornt. 10a. For All Wells: Submit this form within 30 days of completion of well
69.Well IDII: abandonment to the following:
Division of,Water Resources,Information Processing Unit,
6b.Total well depth: (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this f6rm within 30 days ofcompletion of well
6c.Borehole diameter: (in.) abandonment to the following: "
6d.Water level below ground surface 14 6t �" (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
W. 1
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length,(if known): T (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment Zthe county health department of the county
6E Inner casing/tubing length(if known): (ft.) Where abandoned.
1
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013