Wake_Well Abandonment_ (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contac or Information: WELL ABANDONMENT DETAILS
Ph 1�tS 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G 0 is heeded. 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 PumpCompany p y FOR WATER SUPPLY WELLS ONLY:
Company Name " HTH
7c.Type of disinfectant used:
G W-073134-2022
2.Well Construction Permit#: 1�2 I b.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
Amount7dAmount 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 ❑ Bentonite Chips or Pellets
❑Geothernal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount f materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7 rovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I A I / ,� p d
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) //� TV ,v M6—VOL /d�
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4.Date well(s)abandoned:
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Sa.Well location:
Lennar Carolinas LLC
Facility/Owner Name Facility IDh(if applicable) 8•C
7500 Green Level Church Road, Apex NC 27523
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Address,City,and Zip Signature of Certified ell Contractor or Well Owner Date
hV�/ake
By signing this form,I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.755975 -78.893993 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)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:
t 1`DFr ���'(7 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft,) `�I'AI 0 2U22 1617 Alai]Service Center,Raleigh,NC 27699-1617
V I`7 6c.Borehole diameter: ® (in.) lOb.For Iniection Wells: In addition to sending the form to the address in l0a
rs J�y= lid above, also submit one copy of this form within 30 days of completion of well
.•• ���� err ��kaltyl¢gyiinent to the following:
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 casting length(if known): (ft.) 10c.For Water Supply&Injection Wells: hi addition to sending the form to tic
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): �... (ft.) abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016