Pender_Well Abandonment_ (11)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CARL CARPENTER 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with rile same
construction/abandonmeni,you can submit one form.
A - 4475 3.5
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit th
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Scaling materials uSed'(theek all that-Tp,ply):
Water Supply Well:
❑Agricultural ❑Municipal/Public ❑Neat Cement Grobt�^� ' •.m s d.,�i Bentonite Chips or Pellets
❑ Sand Cement G ro 1nn,2�
Dry Clay
❑ Drill Cuttings ings❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply(single) 2
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout
❑ Specialty CpT qtT%-,1, ;�f` �p Gravel
❑Irri ation UI
Non-Water Supply Well: ❑ Bentonite Slurry v��:'G}j;�QQ ❑ %ther(explain under 7g)
0Monitoring ❑Recovery
injection Well: 7E For each material selected above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation 5.0 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
08/11/22
5a.Well location: _
JOHNSONS CORNER GRILL
8.Certification:
Facility/Owner Name Facility ID#(if applicable)
9031 US - 421 CURRIE 28435 C-�� �J 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this form, I hereby certify that the well(s) ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0I00 or 2C.0200 Well Construction Standards
and that a copy of this retard 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:
34° 27' 27.25" 780 03' 02.30" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(y)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
G:t.Well ID#:
AS-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
30.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
10b. For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
10.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Iniection 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.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013