Wake_Well Abandonment_ (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Cont r Information: WELL ABANDONMENT DETAILS
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7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well ow er personally abandoning well on his/her property) well construction/depth,only I GW,/0 is needed. Indicate TOTAL NUMBER of
wells abandoned:__
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NC ffa 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-075554-2022 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known ; 1/2 lb.
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 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 01
Nesidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout Gravel
Non-Water Supply Well: ❑ Bentonite Slurry
❑Monitoring ❑Recove ry ❑ Other(explain under 7g)
Injection Well: 7f. or each material selected above,provide amount of materials used:
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❑Aquifer Recharge ❑Groundwater Remediation r; �--/�
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage (
❑Experimental Technology ❑Subsidence Control
7g.
❑Geothermal(Closed Loop) ❑Tracer rovide a brief description of the'abandonment procedure:
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❑Geothermal(Heating/CoolingReturn ❑Other(explain under 7 rur A
A�WM'0
4.Date well(s)abandoned:
Sa.Well location: y, /& 5__ _Aa��, �
ICG Homes LLC �—� .- ��� �Ew
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2116 Blue Haven Court, Wake Forest NC 27587
Ph sical Address,City,and Zip
V�/a l A Si ofC ified Well Contractor or Well Owner Date
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
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.978412 N -78.577275 You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For 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#: RF( abandonment to the following:
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p�� Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) �'ICU� ®a 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: (in,) Ee,ax>w;ii =J above,also submit one copy of this form Within 30 days of completion of well
IJ:v, ` iabonment to the following:
UN P.11,'dC S� (�
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): (ft.) 10c.For Water Suonlv&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy ofrthis form within 30 days of completion
..NENmVw-�1 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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016