WS0100059_MWGW30_20180227

WELL ABANDONMENT 11RECORHD .arrow aiD.eDN Y:
1.Well Contractor[ntormadon: 'I }WELL ABANDONMENT DR AD. ^^J�
ej e^3C-�- % C'�btiS ]a.ForC .,,,. MPT or Cloned-Loop Geothermal Wal having the same
wen coosecwrrvam•(orwe0 owmerpemowny•6a d•nwgweir on ryevpmgeuyl well covshud0orddepthmlylGW-30isnwded. Indicate TOTALNUMBERof
e"a
NC Well conmma ce(d�ifi�a:ion Numbw p✓a}, 'rb.Appro matt volume ofwahr remainmgin well(s): 0 a (gal.)
4- -b ��e W wi_ ���C l, FOR W F.R SUPPLY WELLS ONLY-
CompawName �&'"-, 1�^0 ']GTyp fdisi .Wt..d:
2.Well Co..trued.Permit g:
Livtail apylicable welt rovhusriwyermitr f e_Ulq Connty,bYata Ponnnaa,ens. tJM,mm p
]d.Amount of disio[ectant used: Iv¢ 0 [
3.Welluse(aheekwe0ass):
Water Supply Well: ]e.Sealing materials used(cheele 0 that apply)- '
OAgricultmal funiciPaVPublic ❑Neal Cereent(3amt rd'6 (mite Chipsor Pelleh
DOeothermal(Headng/Cocling Supply) URevdentiai water Supply(single) ❑Send Cement Grout ❑Dry Clay
OladusWal/Coo memial DRaidemal Wetu Supply(shared) ❑Ceucmte Grout ❑Drill Cotm,
Ohri ation ❑Specialtydout f�el
Non-Water Supply Wall: ❑Benmvite Siuuy ❑ONa(explain me.,!g)
OMovitoring (]Recovery
Injectlon Well: ]LFo^reaehmatual I elected gbove,providemomad ofmaterials used:
OAquifu Recharge 0Gmundwatu Remedia0on 12d �eNS
DAquifer Stomgemd Recasuy OSalinity Barrio DAgWfi,rTat DRosenwaterrnainage 09-n'1"0 AV -t e hi PS -o o )a S .
OBxperfmmml Technology OSubaidence Conrcol ]g.Navide.Mel deeeripdav ofbandonamtprb.sd..:
OGmthesmal(Closed Loop) UT. 6(�jQ((ee a,,,,
OGmflomnel a' Cooing Remo) DOlher(axplaiuundu] )
a a7 sdLa�e fo 1h_l
O.Date weD(s)sbaodoved: Y -e- a,C- r` r
S��'e0loatlon:
FxJiVIOwvu Name Peciliry IDN(ifepplicable) B. tlflration:
0A1 s,'v r (V� ,J Qe t we
dCity,-
wry a ^
P Atldms;City,entl Zip n ue a AWetl Cantmdoror Wellowner D
this form. I hereby cernfy that the well(s) was(r)abandoned in
Cowry FmmlldanOcebon No.(yIN). accordance with ISA NCAC 02C.0100 or2C.0200 Well Construction Standards
5b.Lafitude and lotedlude In degreee/minuta/suovds or dedmel degrees: and that a copy fthis record has beenpro&ed m the well owner.
(itwe116e1d,one le'Iwgqis eaiscim9 9.Site diagram or addid...I well&(a,:
V I fl W You may use the back oftbis page to provide addifional well site damns or well
aboadmomidetads. Youmayalsomachaddidoualpagesi£necessary.
CONSTRUMONDEXAMSOFWELL(S)UINGARAMONED SUBMITTAL INSTRUCTIONS
Attach weilcrosnucd•nmoM(e)eJavallaDla FormuMple Udandpnarn•n-watero•yplyxrelty
ONLYWth ehemme cmunuenoNabondo nient you mnsubmnmnefo m. 10a. For All WuH : Submit Us form within 30 days of mmpie0on of aell
6a.Won DM. abendu mesalto Ne folloam,
Divieisnof Watu Resource0.lof•rmaBon Processing Udq
66.Toml well depth: 3 (B) 1617MaB Service Center,Raleigh,NC 2]699-161]
MAR 0 9 2018 1".For IOleetlon Wells: to addition te,sending the form to the address in 10.
6c.Borehole die netor: C (ivJ abase,also submit one copy of this fmm within 30 days of completion of well
3 !.o:=i sbandomvent to the following:
6d.Water level below gemoul,urfue: �� (R) Didsmu ofWahr Aeeourceq Uvdergroundlnjectlon Control Program,
pp 1636Ma0Se ee Center,Iltlelgh,NC2169 9-163 6
6e.Ovmrcasinglength(Ifimown): 3 (? (fl) 10e.For Water Supply&Inieefion Wells: In addition m sending the form to the
aMrees(es)above,elan aabmd one copy of this form within 30 days afmeopletion
of well abandonment m the county hulfis depmtmuN of she county shoo.
6f.In.mnhsg/tubNg length dflmawe): (ft.) abandoned.
6g.Saesu length pfkoown): (&)
F.—GW-30 NmW Cmulwa Depmlo,sa Ofltov omauut Qusiry-Division ofWaler Rmoama Revved 2-22-2016