Pender_Well Abandonment_ (27)

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-waler supply wells ONLY wilh the same
construction/abandonment,you can submit i ne 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#:
List all applicable well construction permits(i.e.County,State,Variance,etc)ij'known 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
�� .=' q rY y
❑ Sand Cement rout a d,•-_ D Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout "'-6-Drill Cuttings
❑ Specialty Grout AUK � J 20222
❑ Gravel
❑Irri ation 0
Non-Water Supply Well: Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery Iflt�.rn-�, g :d�,..h;� Urij
injection Well: 7f.For each material seirctedeabdv{e;,pvovide 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: 08/1 1/22
i
5a.Well location:
JOHNSONS CORNER GRILL
Facility/Owner Name Facility ID#(if applicable) 8.Certification: -
9031 US - 421 CURRIE 28435 C= 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
P E N D E R 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:
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(s)if ovailable. 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#:
AS-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
30.0 1617 Mail Service Center,Raleigh,NC 27699-1617
tib.Total well depth: (ft•)
lob.For Infection 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&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 GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013