Wilson_Well Abandonment_20220805

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
At obey kv Ihnonas
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or Lvell owner personally abandoning well on his/her property) well construction/depth.only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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FOR WATER SUPPLY WELLS ONLY:'^'I^Company Name lc.Type of disinfectant used:
2.Well Construction Permit#: q
List off applicable well construction permils(i.e.U/C,Caum)t State,Variance,etc.)iftmown I
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well-. 7e.Sealing materials used(check all that apply): �p�
❑Agricultural ❑MunicipaltPublic O Neat Cement Grout iO Bentonite Chips ortPeYacz,C E i\/iF D
OGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) Sand Cement Grout WXry Clay
OxndustriallCommercial OResidential Water Supply(shared) ❑Concrete Grout O Drill Cuttings AjJG 0 t^, 2022
ation ❑Specialty Grout 10/ravel -
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain un er g D Prose s.ng Unfit
OMonitoring ORecovery EAVCOOG
Injection Well: 7E For each material selected above,provide amount of materials used:
OAquifer Recharge OGroundwater Remediation 1 I Z —ry ®n
OAquifer Storage and Recovery OSalinity Barrier OAquiferTest OStormwater Drainage MCA)
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❑Experimental Technology OSubsidence Control 7g-provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer � ''
VAOGeothermat(Heating/Cooling Return) ❑Other(explain under 7g) ('� 11 ) P'ft_[1 101
4:Date wetl(s)abandoned: f („�l Oyd
3 J pnrn�e �t n .Sa.Well location: -1Y;1/1t L�(l(�/I 1`1t�i L (�l_(il l(�
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Facility/Owner Name Facility lD#(ifapplicable) 8.Certification:
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Physical Address,City,and Zip �I Signature of CcRi6ed Well Contractor or Well Owner Date
By signing this form,1 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 lat/long is sufficient) 9.site diagram or additional well details:
N -�� �Z�g O You may use the back of this page to provide a
W dditional well site details or well
abandonment details. You may also attach'additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well caustruction remrd(s)ifevodable For multiple injection arnan-watersupply wells,
ONLYtvi[h the same ransrructiorJabatufonment,you can submit oneform. 10a. For All Wellst Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following.
e Division of Water Resources,Information Processing Unit,
6b.Total well depthr, o?J (ft) 1617 Mail Service Center,Raleigh,NC;27699-1617
10b.For Infection 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:
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6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length Of known):' (ft) 10c.For Water Supply&IniectionWells: 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(f known): ([t) abandoned. _
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6g.Screen length Of known): (ft.)
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Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources _ Revised 2-22-2016
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