WM0100512_Monitoring Well Construction and Abandonment Records_20220623

WELL CONSTRUCTION RECORD (GW-1
Print Form
For Internal I )se 0n]y:
1. W'eil Contractor Information:
Well Contractor Namee
N( Well Connac or Cmria�n Vumb� r
FErnVilr'0vtv+Ae_M---1 0(z;1tlYtq d-- P(dbinc� Sp�n+I`Cps
Companv Mine —
2 Well Construction Permit #:
I ;si all applicable well i onsiruclw,) perrna, (i_. ! It'. r ",mnn. :,raty 1 elli;p}<r vtr.; --
3. Well lise (cheek well use):
I Water Supply Well:
E)TvlunicipaUPuhlic
(Heating/Coolin,, Supph) Dkesidentatl vkater Supl)k ismgle)
ammercial [3R silentaal Water Supph (shared)
I, 'lX- Water Supply Well:
l�j!(Monitoring F]Reco% ­�
fer Recharge
fer Storage and Recover,
fer Test
E]Ground%%ater Kcrawdiatio❑
[3Salinity Barrier
IDStonnwater Drainage
Subsidence Control
D1 races"
[DOther (explain under
14. WA
Ct. ft.
ff. fi.
15. OUTER CASING for 1 multi -eased wells OR I N —1 If applicable)
—r -—-- — FROM � "ro IApSI;"('f;R IAICKNI:tiS { \SATF,RLII. -_
--
16. IFRO1 ro TUBING (geothermal dosed-loo - _ -- --
INNER CASING J THICKNK'S- Sta7�Y.RIA3.
157 n. C.l-1-. Li-Q
fk. fL in. i
17
F'ROh7 CO1 DL45iFTN.R bLO7� SrL.}; TnICKhFSS DidTERL-+.1,
C-- -- -- —
! ft.
ft5 tt in.
. ft i __ _ nr � -
18 CROi 7
- -- - -- - - 'v-
-(RVii 1t1 t-_1lttk RLt— t. � ERi PI rt F3- -fi(1D5 kr lIF;3flti \itU[C
-
I
ft. ft }l--
f�---
19.
15 ft. 3 ft_ i # Z rneA (w�2
--- -ft - --- -- ff--------
�20. DRILLiNG UX; (attach additional sheets if veers )
�Ir Ro I TO __L1MSCRIPTf0N (catar, horniness, saxtLr.,ck ri3�. pnio arm, eie}
O ft ft ! 1
4. Date Wel(s) Completed: �9 �� Well I13# T �
' 1
1
_ �_ _ _���
Ql�k__- .ra-v�_._�rave.__.------- ___
_
Sa- Well location:
7 ft
'7 C✓ ft.
rsK }J. r-dw n _ y mv\k
T sw�kS
Ir.)a 8r lniorlr5 ��� k�--
7.S ft.i
! Q rt. f
L+Sautes ShA It r VeA
FacihridOwner Name Facrhi) IDi+ (ifapplicable)
10 ft.13
ft.
Lt. six �C[11 SA.+Vlrx,*j 11•-1
IZ(tc) 5wee+en_ Creek (u_ As>1evi11t INC.
13.
14 ft _'
Sh P i5 of 9rcil •brow" ,eeds
%S,Sand!
Phssicat Addr s. 'its". and /.ip
1 ft' s rt'
i Lt • ?�tiWtf� S,a Y(tJ 5 �Ilq,le5
21 REMARKS
Countti puree! ldeinticalu.n\o iPIN '
'. ---- -- -_-----_. --- .-- — --�._ ---
Sb. Latitude and longitude in degrees; min utes;'seconds or decimal degrees:
(ifwell field, one latlong is sutticient)
22. Certification:
V b�
zZ
6. Is(are) the well(s)OPermauent or EK1.1porarN
SwIlauu oft e-t del ...rtrac Date f
i rm; F i.rn, i .} sort US sFr,, ii i-.n,. it nitec "n aa.ordance
7. Is this a repair to an existing well: O} es or 1'o
w Ih �. _VC , r '_( Ut Uh t r'Jq 4C Qi � �OCi WB .Ons Li.ian b,an nrd and that _t
if this is a repatr fill out known well constriction inli; nrratiori m:;! esplairi [he nalure ofthe
�upt ul�drrs recxird has t r: proruled to the reti ua-n"
repair under =21 remarks section or on the back of this Joan.
23. Site diagram or additional well details:
8. For Geoprobe/DPl or Closed -Loop Geothermal Wells has'ing the same
Y,ou morn rise the buck of this page to pi "vide additional %veh site details of each
construction, onlyI GW-I is heeded_ Indicate F01 AL ,',UMBER of wells
eunstnxtian detail, You nrr} also attach additional pages ff necesklr_.
dolled: ON
S1111-MI I'TAL. INShRI V] IONS
9. Total well depth below land surface: S — fft)
"a. For .,:i Welts: Submi this lbrrn �,vith n 3u dav, of completion of .yell
Fnr rnultrple wells list all delrth.+ i(Jrlier+�nt i -. i; nl%iv a_'Ou un t m D0'1
I -
10ttiti(rUCnlil7 in (17e I(111(:ving
Ill. Static water level below top of casing: _ (ft.
1)iv'ision of 'A ester Resources, Information Prtrcessing Unit,
{fxater level is abo,-e caring, use "'
1617 Mail Service ('enter, Raleigh, NC 27699-1617
11. Borehole diameter: _ (in.)
24b. 1,(1r 1AL-lion e', etis: lr uai„r .., scndnn, the fonn o, the address in 24a
,it ,tc also ;uhrnit t e 0p% „! this lcnu within -`,U days ;,I aavpietiun of well
r` T
12. Well construction method: DIP
c n_truction to the i ill" sing
it e auger_ rotary-, cable, direct push et.
—__
Division of Water- Resources, 1 ntlerground hkicctum Control Program,
FOR WATER StTPLY WELLS ONIA
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) 'Method of test:
24c. For W aier Srrro�th & Injection Wells: lr addition t�- seiidngg tire Ginn to
—
the address(es;i above. also uhniit one copti of this form \%ithin 30 days A'
13b. Disinfection type:_ Amount:
completion of �.ieli construction to the county health depw-anent of the count,
where constructed.
FormG""ith1 .uotmaD. lm nient„1I[m11oruueutai
D1, ,Aurakc,nuiCc, Re,i, d.'._' 2010

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Fto � GlG2d•
W ell Contractor Name for we l owner per�onalhabandoning veii on Fins. her prepertvi
3507
NC Well Contractor Crtification Number
For Lnternal Use O'.JI. �.
I
WELL ABANiDONMENT DETAU S
7a. For GeoprobeiDPT or Closed -Loop Geothermal Wells having the same
well construction -depth, only l GW-30 is needed. Indicate TOTAL NUMBER of
wells abandon�xl:____-. - - ---Q F__-------- _-----.__-_
7b. Approximate volume of water retraining in weli(s): (gaL)
Cn�1tYOVj MQ n � �12ti�1'Vlq P(v6%K5 ,Se(vltLS [FOR WATER SLPPLY WELLS ONLY:
CompanyNamec_ Type of disinfectant used:
2. W'ell Construction Permit q:
i1S( all applicable well construction permits ti.e UIC Courti, State. Panance- etc i rf• iuwn
7d. Amount of disinfectant used:
3. Well use (check well use):
Water Supply Well: 7e. Sealing materials used (cheek all that app
-Agricultural--,Municipal Public - Neat Cement Grout B tomte Chips or Pellets
-Geothermal (Heating/Cooling Supply) -Residentiai Water Supply (single) - Sand Cement Grout ^ Dry Clay
❑Industrial/Commercial-Residcnna; Water Suppl}' (shared) Concrete Cnout - Drill Cuttings
;Irrigation Specialty Gout Gravel
Supph Well:
Reco: erg
Injection Well:
-Aquifer Recharge -Groundwater Remediation
-Aquifer Storage and Recovery -Salinity Barrier
C Bentonite Slum'
17 Other (explain under 7g)
7f. For each ataterial selected above, provide amount of materials used:
1 -Aquifer Test=Stormwater Drainage
-,Experimental Technology -Subsidence Contml
7g. Provide a brief description of the abandonment procedure:
-Geothermal (Closed Loop) -Tracer
Geothermal (Heating/Cooling Return) -Other (expiam under 7g) tt �yAp ,AAwo.5 eyAo� ' - �e
a um cMAl w� 3�iI hele �l+wt �i9 i�i9w1
(o-_1
4. Date wells) abandoned: 9-zz
5a. Well location: K ty f �U 1e pie, -urty*,A to no r'maj CD V(8i-'tM5
WcIf efWOOKS
Facilitv'Owner Niune Facility Op lit applicable i
I ZL© 5 W sc den C,,reek RZ. f�'rshe'06k e ti}c
Physicai Address. City. and lip
C ounry
Parse; identification Nc PIN)
5b. Latitude and longitude in degreesiminutesiseconds or decimal degrees:
it well field, one lat-lone is sufficient!
CONSTRtiCrION DETAILS OF WELL. S) BEING ABANDONED
.4trach well construction record(s) lfavailabie ror.multiple iniection or non -water supo(r wells
D-`'L F w th rite same contraction abandonment. . -u can subm:! .ne form
6a. Well ID#:
6b.'rotalwell depth: 75 (ft.)
6c. Borehole diameter: 3 (in.)
S. Certificatiou:
tine o,' Ccnifie c -o ctor or Nell ( Date
;roiling thus form. 1 hereby certifi r the weilr was :were,, abandoned in
accordance with ISA . 'C,fC 0' 106 or ?C 0200 Weli Construction Standarw
and tat a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
anandonment details You may also attach additional pages ifnecessary.
SUBMITTAL INSTRUCI-IONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Divuion of Water Resources, Information Processing unit,
1617 Mail Service Center, Raleigh, NC 2769-9-161'
10b, For Injection Wells: in addition is sending the form to the address it,, 10a
a'ooce. a so su'omit �,ne cop,, �ii, this fora: within 30 days o completion of well
abandonment t� the following
6d. Water level below ground surface: JL) Division of �' ater Resources. L nder-ground Injection Control Program,
i636 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): � f + (ft) lOc For NN ater Supply & Injection 'A ells: In addition tc ;ding the form to the
1--- addressees) abo%e, a;so submit one cop}' of this form within ;_' days of completion
•.yell abandonment t, 'hc .:Oun"T health department the counh where
6f. Inner casing/tubing length (if known): (fL) abandoned
6g. Screen length (if known): _(fin)
Form GW-30 North Carof¢ia Depanmeet of Envvonrricmid 0a ljt. - Division o: Vs aicr Rexsurce� Rcyiscd 2-22-2u Ir`