Wake_Well Abandonment_20220607

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
AWellContract
ntractor form on, WELL ABANDONMENT DETAILS7a.Number of wells being abandoned:Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
33 3 R consrnrctionlabandonment,you can submit one form. A,
7b.Approximate volume of water remaining in well(s): TY �� (gal•)
NC}I(q)I o actor rti ation ymber
111J�1J � r(LW55"Ot' FOR WATER SUPPLY WELLS ONLY:
Company Name // 7c.Type of disinfectant used: A l
2.Well Construction Permit k: 'V
List all applicable well permits(r.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
EOAgricultura,l
pply Well: .Sealing materials used(check all that ap y):
❑Municipal/Public Neat Cement Grout Bentonite Chips or Pellets
ma (Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
al/Commercial OResidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
n ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well ❑ Bentonite Slurry ❑ Other(explain under 7g)
onitoring ❑Recovery
7E For each material sal clad ab ve,provide amount of materials use
njection Well: � r
❑Aquifer Recharge ❑Groundwater Remediation i Q s P/J`6 /1t tl � J,0 9�s IV
❑Aquifer Storage and Recovery ❑Salinity Barrier 30�i Jr
t
❑Aquifer Test ❑Stormwater Drainage W r+'° (•�'�`
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descry tion of the ab ndonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Q II p,�,i� U /Q� �Z 16 Pella a• ie e&/z
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) T f µe �'! N [ ' t
3 3l Z z L.: *V t�ve� cep 0� -' `
4.Date well(s)abandoned: t
JUN p 20 ,fp , Il"q , , � � 14
52.W I IocaVon: !�
�t?� C informalien Qrozwurng UnipA41
Facility ID# rfa tb + 8•Certific ion:
Facili /Owner Name t ( pp 3 /2,
�39IZ W/esfe ,n Aid®, �,l�g� ��. Z�b�b
Physical Ad yes,City,and Zip Signa of rtified Well Contractor or Well Owner Date
Q By signing this form, I hereby certify that the well(s) was(1vere)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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
p 1, p ` You may use the back of this page to provide additional well site details or well
3St ,j y Z— N Q Q t 6 9�� 5'� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/bandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well IDN:
Division of Water Resources,Information Processing Unit,
( 1617 Mail Service Center,Raleigh,NC 27699-1617
fib.Total well depth: �� (ff.)
10b.For Infection Wells: In addition,fo sending the form to the address in 10a
au above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: o -(in.) abandonment to the following:
r Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: i iQ (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
t 10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): 'd (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
where abandoned.
6E Inner casing/tubing length(if known): A (ft•)
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013