Wake_Well Abandonment_ (8)

ELL ABANDONMENT RECO W For lntemal Use ONLY:
1.Welveyintractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed'Loop Geothermal Wells having the same
Well ontractor Nam .or well owne personally abandoning well on his/her property) well construction/depth,only 1 G�-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
N.W. Poole Well and Pump Company FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
G W-078583-2022 7e.Type of disinfectant used:
2.Well Construction Permit#: 1�2 lb.
List all applicable well construction permits(i e.U/C,County,State,Variance,etc.)if known
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 Grout Kentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) *esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Iri ation ❑ Specialty Grout b&ravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation G i
43 cif► � .:
❑Aquifer Storage and Recovery ❑Salinity Barrier /}
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer 7 vide a brief description of the abandonment procedure:
� •, ��
❑Geothermal (Heating/Cooling Return ❑Other(explain under 7
4.Date well(s)abandoned:
5a.Well location:
Helix Ventures LLC Well #1 -67
Facility/Owner Name Facility IDN(if applicable) 8. rtification: ®
4112 Friendship Road, Apex NC 27539
Ph sic al Address,City,and Zip Signature of C We Contractor or Well Owner Date
= �
Wake Werti
By signing this fortn,1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record luu been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.672726 N -78.905605 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
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,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:
S: 1, Pr
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) J U N A' o 1617 Mail Service Center,Raleigh,NC 27699-1617
2020
.
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) l IRJ above,also submit one copy of this iform within 30 days of completion of well
i P� Stment to the following:
t, 3i
6d.Water level below ground surface: ! (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Cof c-,A- (ft.) 10c.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 couny health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i