Yadkin_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY: j
1.)}'ell Contractor Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-L o{ p Geothermal Wells having the same
Well Contractor Name Kr well owncrpersonally abandoning well*on his/herproperty) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number _ R 7b.Approximate volume of water remaining in well(s): 16
YADKIN WELL COMPANY
FOR WATER SUPPLY WELLS ONLY:
Company Name '•� J v ,17c.Type of disinfectant used: rhJb t-AX-
2.Well Construction Permit#: P•J �-�,`'•7
List all applicable well construction permits(i.e.UIC,Counry,State,Pa�ia(tr"�rl;ty. town
t,0, ✓ 7d.Amount of disinfectant used: oz
3.Well use(check well use): fin"
Witter Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M icipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) t esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 2"C'oncrete Grout O Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
N'dn-Rater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation t I �tv e-
❑Aquifer Storage and Recovery ❑Salinity Barrier J
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer 7g,provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) UtM Q' fStA�T (� i 1 t /Yjl+�1. D7Toiyt
4.Date well(s)abandoned: / I J� Ot� r / rr ` 1 7Cceno
q
5a.Well location:
✓ d'` o1//hb%K (fp
Facility/Owner Name Facility ID#(if applicable) 8.Certificat' `ry �r ����
. K:zl S: je. -I
Physical Address,City,and Zip Signature ofCcatified W tractor of Well Owner Date
' -( By signing this font, I hereby cert�that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 01C.0100 or 2C.0100 Well Construction Standards
and that a copy of this record has been provided to the well owner.
6b.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:
r, Cj 7 r �i N �^ e 1:J G+�r W You may use the back of this page to provide additional well site details or well
abandonment details. You may als9 attach additional pages if necessary.
Ca ONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auch well construction record(s)ifovailable.For muhiple injection or non-water supply wells
0tvL1'with the some construction!abondonmenr,you can submit onefona.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: '� abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Smice Center,Raleigh,NC 27699-1617
10b.For Injectiou 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:
6d.Water level below ground surface: ' / 170 Division ofWater Resources;Underground Injection Control Program,
`� 1636 Mail Service:Center,Raleigh,NC 27699-1636
7 Ge.Outer casing length(if known);: (ft.) 10c.For Water Supply&Injection 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 to the county health department of the county where
Gf,Inner casing/tubing length(if known):
(ft.) abandoned.
6g.Screen length(if known): (ft.)
f�.il r 6
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
IP 33 6 -