Pender_Well Abandonment_ (26)

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-woler supply hells ONLY with the same
cotnsiruclion/abandotmtenl,you can submit bne form.
A - 4475
7b.Approximate volume of water remaining in well(s): 3.5 (gal-)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction perntiis(i.e.County,State.Variance,etc)ifknoum 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 Ceme'f C,rouf';`� " '''`.. •❑'.Bentonite Chips or Pellets
� t ,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑ Sand Cement Ciro'iit' ' c5�Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout A Ir t) Q 20?2 ❑ Drill Cuttings
❑irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: Ben tom e( {�rsyn',, ,�� ? �7'`'"'.i'-J (-fl;bther(explain under 7g)
OMonitoring ❑Recovery J1 va
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑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: 08/1 1/22
Sa.Well location:
JOHNSONS CORNER GRILL
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
9031 US - 421 CURRIE 28435 L-f 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing lhis form, 1 hereby certify that the well(s)ivas (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]at/long is sufficient) 9.Site diagram or additional well details:
34 o i 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(,)if available. For multiple it jection or non-crater supply
use//s ONLY with the same consirticiiontabamlomnet7t,you can submit one form. 1 Oa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AS-5 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.'rotal well depth: 30.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in iOa
above,also submit one copy of this form within 30 days of completion of well
Gc.Borehole diameter: 2'0 abandonment to the following:
Gd.Water level below ground surface 8.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&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.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
Form OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013