Wake_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information':/ 1 WELL ABANDONMENT DETA"'
U` ivy Le-4l1JCJ l�h 7a.For Geoprobc/DPT or Closed-Mop
I/ op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I OW-30 is needed. Indicate TOTAL NUMBER of
430 r� /t wells abandoned:
NC Well Contra(-ct�or Certification Number 7b.Approximate volume of water remaining in well(s):�_(gaL)
11 eLtbc � FOR WATER SUPPLY WELLS ONLY.
Company Name Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction pemill s(i.e.U/C County,Stale,Yariance,etc)iflmown
7d.Amount of disinfectant used: [
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheek all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout CAentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ❑Sand Cement Grout Clay
❑lndustrial/Commereial ❑Residential Water Supply(shared) ❑Concrete Grout E C . uttings
❑Irri ation ❑Specialty Grout ❑qq qGravel
Non-Water Supply Well: ❑Bentonite Slurry MAY 3 1 20 Other(explain under 7g)
❑NIonitoring ❑Recovery
Injection Well: 711 For each materi ►rAW38r91;:rN%i4 Q t of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /��6 LS
❑Aquifer Storage and Recovery ❑Salinity Barrier II {�
❑Aquifer Test ❑Stormwater Drainage
T
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / j
❑Geothermal(Heating/Cooling Return) OOther(explain under 7g) � A (. d, (,,/1 A
4.Date well(s)abandoned:
Sa.Well location:
DVA l-C
Facility/Owner Name Facility IDi{(ifapplicable) 8.Certitication: ol
1�05-
PIhyysiical Address,City,and Zip l— Signature of Certified Well Contractor or Well Owner to
J!`� OtL By signing this form,I hereby cert�that the wells)ivas(were)abandoned in
County Parcel identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 IYell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstructionrecord(s)(favailable.Formulriple injection ornon-watersupply%yells
ONLYwith.the same construcdon/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•. abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 0t.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For iniection Wells: In addition to sending the form to the address in l0a
6c.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: 30 (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft,) lOc.For Water Supply&Inicction 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
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 Noah Carolina Department of Environmental Quality-Division of WataResources Revised 2 22 2016