Granville_Well Abandonment_20220616

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Zo i_ T 3 10 lco- cz-1 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2�/ ! wells abandoned:
r
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name / Z&
7c.Type of disinfectant used: ``�(
2.Well Construction Permit#: 7 6
List all applicable well construction permits(1.e.UIC,Courify,State, ariance,etc)ifknown
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 fY)gentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) WSand Cement Grout ❑ D❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ 13516r, -
❑Irrigation ❑ Specialty Grout ❑ Gravel ((���
Non-Water Supply Well: ❑ Benton a Slurry El Other(ex`piam under 7gtt)`,��
❑Monitoring ❑Recovery t�``��
Injection Well: 7f.For each material selected above,provide amount of au".
❑Aquifer Recharge ❑Groundwater Remediation I ?
? f A left
t �WI ESMO IJN+
[]Aquifer Storage and Recovery ❑Salinity Barrier ��
❑Aquifer Test ❑Stormwater Drainage 2 e o 4-e- g
❑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) P6 us.
4.Date well(s)abandoned: y ^ZZ
5a.Well location:
190.6eg "-�f � y
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6634 1-64 6 5
Physical Address,City,and Zip Signal.'_='o'lTertified Well Contractor or Well Owner Date
� 1C�P 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
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:
(ifwell field,one Iattlong is sufficient) 9.Site diagram or additional well details:
3 Z 3 O7- N g „ 3• ' W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit one form.
�I 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• ('J �� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: Z '-6a (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (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: T C7 (fo 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&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 where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): d (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016