New Hanover_Well Abandonment_ (9)

WELL ABANDONMENT RECORD For Internal tJseONLY
1.Well Contractor Information: WELL ABANDON YIENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner peroually abandoning twiavlreGl pytl j•.�. well construction,'depth,only 1 GW-30 is needed. Indicate TOTAL,NUMBER of
2725-A v � y ��' 'Fells abandoned:
NC Well Contractor Certitication Number ^ 76.Approximate volume of water remaining in well(s): <1
ET FOR WATER SUPPLY NN ELLS ONLY:
Company Name IroCln",s►; ( -7,7 a.., Ur is
r7r,� "viOG 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well constnection pemins(i.e.UIC,County.State, l8riance,etc.)if kwoxar
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑NfunicipallPublic S Neat Cement Grout O 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
❑Irrigation CJ Specialty Grout D Gravel
Non-Water Supply Well: ❑ Bentonite Slun)' -Other(explain under 7g)
M\Ion itoring ❑Rcco%cr%
Injection Well: 7C For each material selected above,provide amount of materials used:
❑AyuiferRecharge IlGroundwaterRemediaticm 15 Ibs portland cement -1 gal water
❑Aquifer Storage and Recovery f7Salinity Barrier --
ElAquifer Test ❑Stormwater Drainage
❑F.xperimeutal Technology []Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Removed well cover and concrete pad. Filled MW
with neat cement through tremie pipe. Restored ground
4.Date well(s)abandoned: 8/1 8/22
surface.
5a.Well location:
Former Winter Park Cleaners DC650013
Facility/Owner Name ---_—_"—__--- 8.Certification:
1437 College Rd, Wilmington 28403 8/18/22
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Physical Address,City,and Zq' `trnuwre I t'rrY' d Well Contractor or Well caner Dote
New Hanover
3r signing this Jornr. 1 herrhr cerYilr that the trell(s) vas (it-ere) abandoned in
Count% Parcel Identification No (PIN) accordance ivith 1 A AVAC 02C.0100 or 2C.0200 lVell Consnimtron Standards
and that a coph q this record has been provided to the it ell otrner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cif well field,one lac long is sufficient) 9.Site diagram or additional well details:
34 12 38.516 N 77 53 09.881 YY You may use the back of this page to provide additional well site details or well
abandonment details. You nnav also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atrach well constnrcnatrec•ord(s)ifavailahle. For mtdapleiniectionor non-water sapplvwells
ONL I'vilth the same construction abandonment,cot can suhmt r one loan.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W 4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.11orehole diameter: 1 (PVC) (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: �9 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sumaly&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
611 Inner casing/tubing length(if known): 7 (g,) abandoned.
6g.Screen length(if known): 10 (ft.)
Form G1V-30 North Carolina Department of Environmental(Quality-Dwision of Water Resources Revised 2=2-'016