Rowan_Well Abandonment_20220701

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1.WeII Cont actor Information: �� WELL ABANDONMENT DETAILS
(� 4 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on lvs/her property) well construction/depth,only GW-30 is needed. Indicate TOTAL NUMBER of
L15�6-
A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): C) (gal.)
Morgan Well & P u rn p,r I N C FOR WATER SUPPLY WELLS ONLY:
Company Name granulated chlorine
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�C)q :. i 7c.Type of disinfectant used: g2.Well Construction Permit#: lJ I l t
List all applicable well construction permits(Le.UIC,Count),State, Variance,etc.)ifknown I �2
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 AlUentonite Chips or Pellets
❑Geothermal(Pleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared)- ❑ Concrete Grout ❑Dr-ill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply WeII: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection-Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge El Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage K-�• + �,�.
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment r ced e•
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
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4.Date well()s abandoned:
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5 . ell location:
Facility/Owne Name �acility ID#(if applicable) 8.Certification:
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Physic Adndress,/City,and Zip �I/�r Signature of Certified Well Contractor or Well Owner Date c2�
�",`'�� I I t` �O B signing this form, I hereby certify that the wells was Were abandoned in
y �. a f y � lJ (Were)
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.
Sb.Latitude and longitude in"degrees/minutes/seconds or decimal degrees:
(if well field,one a fficient) 9.Site diagram or additional well details:
S� N �O S ��g W" You may use the back of this page to provide additional well site details or well
su
yyy abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the some construction/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:
f' i 1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: 0. (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: C (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: �Q (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&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): 6 (ft.)
Form GW-30 ;North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2016