Wake_Well Abandonment_ (13)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.W ntractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
We Contractor Nam or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-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 ''i HTH
G W-071384-2021 7e.Type of disinfectant used:
2.Well Construction Permit#: 1�2 lb.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if bwwn
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 XBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) �iesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial i❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout Gravel
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 � �
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater DrainageJ '►=��'O/pia►' f
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal Heating/Cooling Return ❑Other(explain under 7 )
4.Date well(s)abandoned: f }/6
oi5AA0
Well location:Flora
/_ )f`�-fj
Flora Development LLC
Facility/Owner Name Facility ID#(if applicable) 8• rtification:
330 Towerview Court, Cary NC 27513
Ph sic al Address,City,and Zip Signature ofCe tfd a Contrac or or;Well Owner Date
1�lake
By signing t , 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
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.801717 N -78.813087 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.Far multiple injection or non-water supply wells
ONLY with 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 ID#• . bandonment to the following:
IJ
a r• Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) Al O c} ?A71 1617 Mail Service Center,Raleigh,NC 27699-1617
31UN i7 10b.For Injection Wells: In addition to sending the form to the address in I0a
6c.Borehole diameter: (in.) ri9i �`,�aboviOiso submit one copy of this'form within 30 days of completion of well
Woigdonment to the following:
6d.Water level below ground surface :f tt) Division of Water Resources,Underground Injection Control Program,
A�71 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): --(ft.) 10c.For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): —� (ft.) abandoned.
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6g.Screen length(if known): A)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016