Wilson_Well Abandonment_20220531 (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
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY tivith the same
C -4421 construction/abandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): 3.25 _ (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable tivell construction permits O.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Ceme ;9n i I" Bentonite Chips or Pellets
❑Geothermal Heatin Coolin Supply) ❑Residential Water Supply sin e ❑ Sand Ceme t mut• a �Y V❑Dry Clay
( � g PPY) PPY( � )
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout MAY 3 ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: El Bentonite 1R5arr5� D l 'i Nam'"9 ether(explain under 7g)
OMonitoring ❑Recovery 1
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
[]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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 04/04/22
5a.Well location:
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1313 WARD BLVD WILSON 27893 �"''`�I'� '"'"' 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 1C.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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 11 e 11
43 12.53 77 56 08.02 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY tivith the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well DN/:
M W-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 4.0 (ft,) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
i
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013