Caldwell_Well Abandonment_20220815

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well ContractorInformation: / WELL ABANDONMENT DETAILS
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,aw 6��� l O W AC✓ 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water` supply wells ONLY with the same
construction/abandonmeni,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): Z (gal.)
31'3 2. bToncy t3rwe�C At.� Lwitl NL 2.,% FOR WATER SUPPLY WELLS ONLY:
Company Name lc-Type of disinfectant used: 3 SIC C k W AO E 7 390
2.Well Construction Permit g: W P f4 q$L
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known
7d.Amount of disinfectant used: L�►?
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ff-Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout eGravel
Non-Water Supply Well k ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ... �] ecovery
Injection Well: 4 .• n�7 7f.For each material selected.above,provide amount of materials used:
❑Aquifer Recharge P.11C' ! "❑ rotmdwaterRemediation Ceo%*AA !Arbui 2 u1e
❑Aquifer Storage and Recovery "�
InfconaAta `er
s��r�. 1 te..l c
❑Aquifer Test DDk.4gQJ rmwater Drainage N....O
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer n
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Junta to e�E t.7�}Gr Chlnl.n� WC
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Aa...�rare I a S7 FhQ. 1d:4- S
4.Date well(s)abandoned: $' L' Zb Z Z Ihar. QMtA� �r i
„c,{c .wtT C[Met+y A�ru}
Sa.Well location: if �'11atn �{ut otaet `tt �Itlelt.
34+1 CA?'kes A w l!1
Facility/Owner Name Facility IDi!(if applicable) 8•Certification:
313 2 Sf" $r k- p r. , Cwir, /JG
Physical Address,City,and Zip Signature o Certified Well Contractor or Well Owner Date
3$1(a13 By signing this form, I hereby certify that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-wager supply
wells ONLYwith the some constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDIi:
® d m abandonent to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 2 Oe (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this forth within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 1- (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Jor _(ft) 10c. For Water Suoaly&Iniection 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,lto the county health department of the county
where abandoned.
6L Inner casing/tubing length(if known): ft)
6g.Screen length(if known): ' (ft)
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013