New Hanover_Well Abandonment_ (10)

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: N1FLL ABANDONNIENT DETAILS
Mike Tynan 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contiactor\ame for well owner personally ab tiiuy well construction depth,only 1 Gbh'-30 is needed. Indicate TOTAL. \U\[BEK of
2725-A wells abandoned:
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',ell Contractor Certilicanon Number A.IJ IV, ZOZZ 7b.Approximate volume of water remaining in well(s): 2 (gal.)
IET
l URa FOR WATER SUPPLY•R_E1.I,6 ONLI':
'ompanyName ,rp i
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well consruchon permits(i e. UIC.Counte.State, 6Lriance.etc.)i%671o1n
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check sill that apply):
❑Agricultural ❑iVlunicipaUPublic 0 Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Tleating/Cooling Supply) ❑Residential Water Supply(single) n Sand Cement Cn-out ❑ Dry Clay
GIndustrial,Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation [J Specialty Grout C Gravel
Non-Water Supply Well: Bentonite Slurn Other(explain under 7g)
ER Monitoring ❑Recover
Injection NNell: 71.For each material selected above,provide amount ofmaterials used:
❑Aquifer Recharge ❑GroundwaterRemediation 25 Ibs portland cement ^-1.7 gal water
❑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
❑Geothermal(hleatingiCooline 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.
Sa.Well location:
Former Winter Park Cleaners DC650013
Facility/0'iner lame R.( erlification:
1437 College Rd, Wilmington 28403 8/18/22
xu
PhY'sical Address, nil lip ,,_ a rotor or Well Owner Date
New Hanover
By signing tLn erns. I herehr ceIII& that the it was (ucre) abandoned in
count\ Parcel Lienuriceuon No-(PI'y i accordance with 1 A,'CAC 02C.0100 or 2C.0200 Il,,//Constivotron Standards
and that a cop['of this record has been provided to the[tell otrner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if.c II I Od . W ,t 1"TV Ix sufficient) 9.Site diagram or additional well details:
34 12 37.930 N 77 53 08.664 ��, You may use the back of this page to provide additional well site details or well
abandonment details. You mar also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constnrcdonrecordi)ifwailable. For multiple s»jectionor non-water supply wells
ONL F with the same construction ahand ntment,you can suhnut one li)rm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• M W 5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 14 (B) 1617 Mail Service('enter,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (PVC) (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.NN titer level below ground surface: �5 (D) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 7 699-1 636
6e.Outer casing length(if known): (ft.) 10c.For Water Sunnly&Ltfection Wells: In addition to sending the form to the
address(es)above,also submit one cope of this firm within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 4 (ft.) abandoned.
6g.Screen length(if known): 10 (ft)
Form G1V-30 North Carolina Department of 6ncironmental Qualitv-Division of Water Resources Revised 2-22-2016