Craven_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JOHNNY BURR I 1
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 some
construetioWabandonment,you can subn`rii one form.
A - 3098 G
NC Well Contractor Certification Number 7b.Approximate volume of wateri remaining in well(s): 0'S (gal.)
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GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
Olndustrial/CommerciaL es e•tial Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation '� �e �I ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ((��'' O Bentonite Slurry ❑Other(explain under 7g)
[?]Monitoringpi�� P 2�C9Zcovery
Injection Well: URA 7E For each material selected above,provide amount of materials used:
is C,G:U oundwaterRemediation❑Aquifer Recharge jnc.m�:y 0.75 GALLONS
❑Aquifer Storage and Recover}- ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 06/30/22
5a.Well location:
INTERNATIONAL PAPER
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1785 WEYERHAEUSER ROAD VANCEBORO 28586 07/18/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
CRAVEN By signing this form, I 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:
35o 12' 50.07" 77o 06' 59.67" You may use the back of this page to provide additional well site details or well
N �'I' 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-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: PZ-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
17.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection Wells: In addition to sending the form to the address in l0a
1.0 above,also submit one copy of this form within 30 days of completion of well
tic.Borehole diameter: (in.) abandonment to the following:
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3.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
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10c.For Water Water Suyniv&Infection Wells:Infection Wells: In addition to sending the form to .
6e.Outer casing length(if known): (ft.) 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 abandoned.
6E Inner casing/tubing length(if known): (ft.)
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6g.Screen length(if known): (ft.) `
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013
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