Person_Well Abandonment_20220616

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well ]
Contractor Infformationn: WELL ABANDONMENT DETAILS
(
, / If L✓g).,14 'p 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
j o�� wells abandoned:
NC Well Contractor Cenification Number / 7b.Approximate volume of water remaining in well(s): (gal.)
F—A p,tf ie-PL(, C2)e'J� l�%7/�!1,e �f{( � FOR WATER SUPPLY WELLS ONLY:
Company Name : l 14
f 7c.Type of disinfectant used:
2.Well Construction Permit#: � I,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ijknown
7d.Amount of disinfectant used: �t-� C y J�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout J<BergtoWte.Chjbs QrYg1lets
❑Geothermal(Heating/Cooling Supply) rib sidential Water Supply(single) ElSand Cement Grout El Dr Cfa 'ri "u ` t" n
Vre
❑Industrial/Commercial DResidential Water Supply(shared) <Concrete Grout Drill Cu�` v 1 s zozz
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 71.For each material selected above,provideaMiott$it of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 t t 6
❑Aquifer Storage and Recovery El Salinity Barrier {'
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /� �►/
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
er 6K LCri x 4y
4.Date well(s)abandoned: A •� Z �'2 ��t( --yy
5a.Well location:
1A"1/ i"
Facility/Owner Name Facility ID#(if applicable) 8.CertiZti �+1!. .�
4
Physical Address,City,and Zip Signature o Certified Well Contractor or Well Owner Date
P0'4 o' ?'Vn5� r B signing this form, I hereby certify that the wells was were abandoned in
�- �� y Z }� g g f y � r� ( )
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 tat/long is sufficient) 9.Site diagram or additional well details:
Y C �' � N _? �� 6 I�r 1 You may use the back of this page to provide additional well site details or well
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abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.41tach well construction records)ifavailable. For multiple injection anon-watersupply wells
ONLY with the same construclion/abandonment,you can submit one form.
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: 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:�(J (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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 Supply&Iniection 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
6t:Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016