Durham_Well Abandonment_20220614

WELL ABANDONMENT RECORD For lnternaluse ONLY
:
Contractor Information• WELL ABANDONMENT DETAILS
1.Well Conlin .
7a.For GeoprobeMPT or Close&Loop Geothemal Wells having the same
Well Contractor Name`(or
/wt ll personally abandoning well on his/her property) well conslmchon/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
welts abando�d:
�— 7b.Approxhnate volume of water remaining inwell(s): (gal.)
NC well ntractor certification Number
r, � �C ( FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: e41l e'er 1_ APJ) w
2.Well Construction Permit#:
List all apphcabte well a0mS6ucB0nperrratr(ta VIC Cou rt,,Start Va a=Ea eta)iflo»wn 7d.Amount of disinfectant used•
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all hat apply)'
❑Agricultural ❑Mum " lic ;;and
CementGrout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single) Cement Grout O Dry Clay
❑Indushial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation _ ❑SpecialtyGrout ❑Gravel
Non-Water Supply Wewjj , '^ U ❑Bentonite Slung ❑Other(explain under 7g)
❑Monitoring ❑Rer�tteay
Injection We1L• 7L For each materiel selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation (c
❑Aquifer Storage and Recovers! ( , Jer
❑Aquifer Test $AMARM3�st y th
water Drainage
❑Experimental Technology ❑Subsidence Control 7g Provide a brief descriptionof the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other lain under 79) OM 61r,
4.Date wcH(s)abandoned: © -
5a.Well location
�11� ' 1sl�lr� �1r
Facility/ ame Fbc'' M#(if applicab1c)� S•Certification:
S Q�od, 05 d� 08 es �.
Physical Address,City,and Zip �Ct� 3��jai i _2CL1A Signature ofCertitied WdkSpractoior well Owner Date
By sigrring this form I hereby certify that the well(s)was(were)abandoned in
co-ty Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C_0200 Well Construction Standards
and that copy of this record has been provided to the well owner.
5b Latitude and longitude in degmeslndnutedseconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagra n or additlomtl wen details:
l Q Q, gQ t7 g q You may use the back of this page to provide additional well site details or well
`1 8 N Ll t 9 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELUSI BEING ABANDONED SUBMITTAL INSTRUCTI NS
Attach welleowtructionrecord(s)&vailabla For»mlhplenjechOnOr-n-wwersupplytrelis
ONLYwith the same eonstruction/atmndoronen4 you cmrsub-toneform 10a. j!or All Wells: Submit ibis form within 30 days of completion of well
abandonment to the following:
6a.Well ED#-
���� Division of Water Resources,Information Processing Unit,
6b.Total well depth: C oL) 1617 Mall Service Center,Raleigh,NC 27699-1617.
10h,For Xniection Wells:,In addition to sending the form to the address in 10a
6c.Borehole diameter: above,also submit one copy of this form within 30 days of completion of well
abandomucat to the following:
Di
6d.Water level below ground surface: _ (ft:) vision of Water Resources,Underground Injection Control Program,
t_ 1636 Mail Service Center,Rddgb,NC 27699-1636
b 'T lOc For Water Supply&Lriection Wells: In addition to sending the farm to the
6e.Outer casurgleug8r(if/mown): (tl.) address(es)above,also submit one copy of this form within 30 days of completion
wl of well abandonment to the county health department of the county where
6E Inner eashWtubing length Of/mown): 1" ft) abandoned.
.6g Screen length(if 1-wn): )

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