Orange_Well Abandonment_20220708

WELL ABANDONMENT RECORD Fur Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
O-S z 0 7a.For Geoprobe/DPT or Cloud-Loop Geothermal Wells having the same
Well Contractor Nam(or well owner personally abandoning well on his/hor pmperty) well conahuction/depth,only J W-30 is needed. Indicate TOTAL NUMBER of
2�F4r�� wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume orwater remaining in well(s): �D r (ML)
� r
S/0'4/ /VG FOR WATER SUPPLY WELLS ONLY:
Company
Z� 7c Type of disinfectant used: Uf�lUIM 6l1�7
2.Well Cons n Permit q:
Lu(alt app cable will coact (ion permits A..UIC,Cimai Sauce,VW hari ere.)if[me— Z
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
CAgricultural ❑Municipal/Pubiie ❑ Neat Cement Grote ❑Bentanire Chips or Pellets
[]Geothermal(Heating/Cooling Supply) V/-idential Water Supply(single) III Sand Cement Grout ❑ Dry Clay
❑IndustriallCommetcial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
Chri tion ❑Specialty Grout IN Gravel
Non-Water Supply Well: " t lr r- ❑Bentonite Slurry ❑Other(explain under 7g)
[]Monitoring Recovery
Injection Well: JLL I p 7f.For each material selected above,provide amount a materials u
[]Aquifer Recharge JOGround Ater RRemedi ;�n
[]Aquifer Stooge and Recovery IDt�i.�;
[]Aquifer Test ❑SV , bier Drainage
[]Experimental Technology []Subsidertue Control
7g.Provide a brief description of the abandonment procedure:
[]Geothermal(Cloud Loop) []Tracer �- /xI yf�r / C-1, /Y✓O3rG r
[]Geothermal(Hearin Coolin Return []Other(explain under 7 ) 7 e.•�s!
4.Date wills)abandoned:-j?rlyC%C/��� / 7.L t/ Q !SP)f i/N!�'/ 1/ '.✓r/-/t -//>ti
Sa.Well location: / � ^[5��1// �" �L/ w/ �✓�S""w(
flB s J
Facility/Owner Name Facility ON(if applicable) S.Certification:
23/ Z /#0P1FST&/40 eA y Ch�Iyr[G 2Z
Physical Address,City.and Zip {�( Signature of Certified Well Counter"or W Own
®/[�N4-e- •J�y O I� 2,By.signing this firm, I hereby cerq&that the we.11(s) wns(were)abandoned in
County Parcel ldenti0eation No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standard.,
and that a copy of this record has heen provided to the.well owner.
Sb.I,aXtude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laillong is suRcienO 9.Site diagram or additional well details:
9 g— �-7 2 r N 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
Anachxel/cons donrecnrd(s)ifavailable.For multiple in)ecaion anon-aarersupplyaelh
ONLYwiththe comecnnsoucwm/ahamhmmrnr,).,,m.uh it onejrm.
IOa. For All Wells: Submit this form within 30 days of completion of well
69.Well 1Dp: 46/, abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3 9.5 (R,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniecllon Wells: In addition to sending the form to the address in IOa
6e.Borehole diameter: in.) above, also submit one copy of this form within 30 days of completion of Well
�7 /� abandonment to the following:
6d.Water level below ground surface: / : fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center.Raleigh,NC 27699.1636
6e.Outer casing length(if known): (A.) IOc.For Water Suooly&Iniection Wells: lu addition to sending the form to We
address(es)above,also submit one copy of this font within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): NIL' (D.) abandoned.
6g.Screen length(if known): VL)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revived 2-22-2016