Wake_Well Abandonment_ (2)

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: L1_ WELL ABANDONMENT DETAILS
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-�l-- W \ 7a.For Geo robe/DPT or Closed-I:oo Geothermal Wells Navin the same
ellW ContractorName(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
Ll wells abandoned:
INC'Welll&ntractlorCertification Number 7b.Approximate volume ofwater remaining in well(s): IS (gal.)
V D ( ro r i-• FOR WATER SUPPLY WELLS ONLY:
Com any Name 19
f p f � 7c.Type of disinfectant used:
2.Well Construction Permit#: V
List all applicable well construction permits#.e.UIC,County,State,Variance,err-)ifkmoxm /J D
7d.Amount of disinfectant used:_ L.•�D
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munieipal/Publie ElNeat Cement Grout OKBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Itid idential Water Supply(single) ❑Sand Cement C tt— q r Clay
F �j �
❑Industrial(Commercial ❑Residential Water Supply(shared) fi✓Concrete Grou .C C f p rill Cuttings
❑lrri ation ❑Specialty Grout r) ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry MAY 3 1 1.O22 ❑Other(explain under 7g)
❑Monitoring ❑Recovery �� , *2ng URA
Injection Well: 7E For each m3 •�`r/' ��rovtde amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation t by6 1bs --W Hole dpr 1L 2001 1GS [,GnGI"C{C
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
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5a.Well location:
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Facility/Owner Name Facility W11(ifapplicable) 8.Certification:
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Physical Address,City,and Zip gignatitre ofCeni6cd Weff—Contiiictor or Well Owner Drate
"(k By signing this form, 1 hereby cerlify,that the ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well orvner.
(ifwcll 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Artacb well construction record(s)lfavailable.Pormulriple injection ornon-watersupplywells
ONLYwitb the same constnrclionlabandonment,you cart submit one foray.
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: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
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: 'f (i) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft.) 10e.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
6L Inner casing/tubing length(if known): 00 abandoned.
6g.Screen length(if known): (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016