Wilson_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAM ES 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 tivells ONLY ivith the same
construction/abandonment,you can submit one form.
C -4421 3.25
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflatmvn 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 Cement Gr{�u �� a,^ 8ftttonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Gtiittl �.,C i 1 ra-bry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 1 n Drill Cuttings
❑Irri ation ❑ Specialty Grout MAY 3 A �`'��j Gravel
Non-Water Supply Well: ZI Bentonite Slurry nr-.,,,;,;,ip Utbldr(explain under 7g)
OMonitoring ❑Recovery r+ 13Dv
Injection Well: 7E For each material selec d a ove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 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 '"'"` 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 ivell(s)was(were)abandoned in
County Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latflong is sufficient) 9.Site diagram or additional well details:
43 16.22 77 56 ��07.16 You may use the back of this page to provide additional well site details or well
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c N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach tivell construction record(s)if available. For multiple injection or non-tivater supply
wells ONLY with the sane construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-13 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 24.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2'0 above,also submit one copy of this form within 30 days of completion of well
(in.) abandonment to the following:
6d.Water level below ground surface: 5.0 (ft.) Division of Water Quality,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
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.
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality Revised March 2013