Union_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frankie L. Oliver 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) Far multiple h jection or non-[rater supply nrlls ONLY with the same
consttzicriott/abmrdonruent,you can submit one form.
3002A
NC Well Cout acwr Certification Number 7b..4pproximate volume of water remaining in well(s): 0 (gal.)
Carolina Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 70%HTH
7c.Type of disinfectant used:
2.Well Construction Permit#: 22-171
List all applicable well permits(r.a.County,State,Variance,Injection,etc.)i#'known 7d.Amount of disinfectant used., 10 OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agriculmral ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hidust ial/Commercial ❑Residential Water Supply(shared) Wr Concrete Grout ❑ Drill Cuttings
01hi ation ❑ Specialty Gout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: X For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 30 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Completely filled well with flowable fill grout
❑Geothermal eating/Cooling Return ❑Other(explain under 7 r
4.Date well(s)abandoned: 5-26-22
JUN 1 Q 2022
5a.Well location:
Inirerrr=3'ciym FIrD=i:vRt:Unli
AMH NC Development [.vrQ/7.3o�,
Facility/Owner Name Facility To#(if applicable) $•Certification:
3503 Sec-rest Short Cut Rd.Monroe 28110 6-4-22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Union 09-256-003A By sighing this fetch, I hereby cerdJy 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 Held,one lat11ong is sufficient) 9.Site diagram or additional well details:
35.10.608 80.33.507 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)if available. For multiple injection or non-water supply
wells ONLY with the same construction✓abandonment,you can submit onefonn. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
30+ (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
48" above, also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 38 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A A) the
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
6f.Inner casing/tubing length(if known): N/A (ft.) where abandoned.
6g.Screen length(if known): N/A (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resom'ces Revised August 2013