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HomeMy WebLinkAboutAlamance_Well Abandonment_20220817 (2) WELL ABANDONMENT RECORD For Internal Use ONLY: i 1.Well Contractor Information: WELL ABANDONMENT DETAILS Russell James Turner 7a.For Geoprobe/DPT 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 2448-A wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water iemalning in well(s): 30 al.) R.J. Turner Well and Pump, LLC. FOR WATER SUPPLY WELLS ONLY: Company Name YY .r. p.1 _ 7c.Type of disinfectant used:C�LI Q CL t/�i n �l t-C��K.k Ci,O' 2.Well Construction Permit#:5 Q ct W k a List all applicable well construction permits(l.e.UIC,Coun(y,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:/d du nee-5 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural o/N imcipal/Public ❑Feat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings Ohrigation ❑ Specialty Grout ❑Gravel Non-Water 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 �r 1 /Cse �^ 1 rQ ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer (� ` i,o� ❑Geothermal(Heating/CoolingReturn) ❑Other(explain Mde )- T N�K� (2e�n�-"1�.r�� �O ((I e_1 t' ��I tee l n j �, VOu nron, VOka'Or-, l �O(�O'�tf�ld 4.Date well(s)abandoned: 7/a 0 a 0 Je+ k r rtt.L �t-1 ��©u� fr.X . 5a.a..Well location: Facility/Owner Name Facility ID#(if applicable) S.CertiSea'on: a�so(o trcLei� f�-Ue. 6ur1;�e��4ot,.a��eS 2_ 7/�D/boa Physical Address,City,and Zip rgna re of Certified ntractor or Well Owner Date Wamanee- <`0 13a3 By signing this form, I hereby certify that the well(s) was(were)abandoned in County Parcel Identification No.(PIN) accordance with I SA NCAC 02C i 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: 3���� N ^ ?�.W 3 ek 5�'S �, You may use the back of this page to provide additional 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 construction record(s)ifavailable.For multiple injection or non-watersupply wells ONLY Wilt the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this forth within 30 days of completion of well 6a.Well ID#: abandonment to the following: Division of Water Resources,Information Processing Unit, 66.Total well depth: (ft.) 1617 Mail Service,Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: _(in.) above,also submit one copy of 4this form within 30 days of completion of well abandonment to the following: 6d.Water level below ground surface: yzv (ft.) of Water Resources,Underground Injection Control Program, � 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if(mown): U h l4.y W f*,- (ft.) 10c.For Water Supply&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 to the county health department of the county where 6L Inner casing/tubing length(if(mown):110%!r\r\e abandoned. 6g.Screen length(if known): R D Screen (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 �4L .C- ' �- t s 0