Wake_Well Abandonment_20220718

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will 7a.For GeoprobdDPT 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.
2700 b welIs abandoned:
NC We11 Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal:)
East Coast.Environ mental PA FOR WATER SUPPLY WELLS ONLY:
Company Name Ch'lorox col shock
7c.Type of disinfectant used: p
2.Well Construction Permit#: na I'
List all'appllcable ti elf consiruction permits(i.e.UIC,County,State,Variance,era)t"nil ar 6 OZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural I7Municipal/Public ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) IlResidential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply.(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation ❑.Specialty Grout ❑Gravel
Non-Water Supply Well: _ ❑Bent_onite Slurry ❑Other(explain under 7g)
Omonitoring-` ❑Recovery
Injectio"Well: 7C:For each material selectedapove;provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Gravel placed from 345'-to 80'bls Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test 'OStornwaterDrainage Concrete placed'80'to land surface Poured in top of well
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment-procedure:
❑Cr eothermal(Closed Loop) ❑Tracer-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 6 oz of pool shock poured i;n well followed:kiy filling
with gravel to 80' bls. Final 80'of well
a.I)ateweu(s)abandoned: 7-6-22 was filled with concrete to land surface
Sa.Well location: I.
Hudson 6401 Property Phase II: na ,
'Facility/Owner Name Facility ID#(tfapplicable) S.Certif- on:
888 7th Avenue FL 19 New•York NY 10106 /f
, 7-6-22.
Physical Address,City,and Zip Signature of Certified Well Conttactor or Well Owner Date
Wake 17366959/2
By signing this form;1 hereby certf that the well(s)was(were)abandoned in
County Parcel Identification A*o..(PIN) accordance with 15A NCAC 02C..0100 or 2C.0200 Well Construction Standards
and that a copy ofthis record has been provided to the well oivner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwem field,one 1aUlong is sufficient) 9.Site diagram or additional well details:
35.864616" N -78.539645" w You•may use the,back of this pageto provide additional well site details or well
abandonment details. You may also-attach additional pages ifnecessary.
_ _CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS_.
Attaclnrellconrtructionrecord(s)olavallable. rOF-ItipICinjectiOnorn6n-waiersuppiyWQIS -
ONLYwith the saa1mef�construcuonlabandonment,yeu can submmiitt one fonnng. 10a For All Wells: Submit this form within 30 days of completion of well
6a.WcII;ID#:'Vy—�: ,P :abandonmenttothefollowing:
�I U L 1 202V� Division of Water Resources,Information Processing Unit,
6b.,Total well depth: 345 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
v,�
� �''sMUTt IMM IOb.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. (m.)ly i; j£j,NE, 'AP�%, =r %,M iIN rpve,also submit one copy of this form within 30 days of completion of well
abandonment to the following.
6d.Water level below ground surface.• 40 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cel a er,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 70 feet (ft) !Oc.For Water Su ply&Iniectio Wells: In addition to sending the form to'ihe
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/tubinglength;(iflmown) N/A. (ft) abandoned.
6g.Screen Iengtli(if known): NSA (fr)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016