WI0800014_Report_20191119

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Joey Cobarobius
Well Contractor Name (or well owner personally abandoning well on his/her property)
4055-A
NC Well Contractor Certification Number
Craigs Well Drilling, LLC
Company Name
2. Well Construction Permit #: W 10800014
List all applicable well construction permits (i.e. UIC County, State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial El Residential Water Supply (shared)
NIrrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date well(s) abandoned: 10/7/19
5a. Well location:
Graham Mosely
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
El Other (explain under 7g)
Facility/Owner Name Facility ID# (if applicable)
2137 Auburn Lane, Wilmington, NC 28405
Physical Address, City, and Zip
New Hanover
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34 15 122 N 77 48 155 W
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: HTH
7d. Amount of disinfectant used: 1 1b.
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout S Bentonite Chips or Pellets
❑ Sand Cement Grout ❑ Dry Clay
❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
❑ Bentonite Slurry ❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Hole Plug 7 bags
7g. Provide a brief description of the abandonment procedure:
Cut well below grade
Disinfected Well
Filled with Hole Plug
Capped with Hole Plug
8. Certification:
it R sage 10/7/19
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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 multiple injection or non -water supply wells
ONLY with the .came ronatrurtion/ahandonment you ran suhmit nne form_
6a. Well ID#:
6b. Total well depth: 54 (ft.)
6c. Borehole diameter: 8 (in.)
6d. Water level below ground surface: 24
6e. Outer casing length (if known): (4° steel)
6f. Inner casing/tubing length (if known): (ft.)
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
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
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
loc. 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
abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-2016