Pender_Well Abandonment_ (29)

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/tier property) For nmliiple ityecdon or non-water supply wells ONLY widt the same
constructionlabandomnent,you can submit one form.
A - 4475 i3.5
7b.Approximate volume of water remaining in well(s): (gal-)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflrnown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing mat rtals used(check all that apply):
Water Supply Well:
❑ Neat Cement JUfout
( ( M—Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public e ., �_ _+(, j 5 .�;
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 17 Dry Clay
9- .J
q Grout i�r_, 2 n
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Z1122 El Drill Cuttings
❑Irri anon
❑ Specialty Grout ❑ Gravel
<-.----��
' 'V'%tt' QMD'Other(explain under 7g)
Non-Water Supply Well: ❑ Bentonite tt�i�"" ,.� a
ElMonitoring ❑Recovery
711 For each material selected above,provide amount of materials used:
injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 5.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
d.Date well(s)abandoned: 08/1 1/22
Sa.Well location:
JOHNSONS CORNER GRILL
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: �f �-
9031 US - 421 CURRIE 28435 L-- r` �f 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 ivell(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 ivell 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 hell construction record(s)if available. For multiple injection or non-water supply
wells ONLY with dte same construction/abandonment,you can submit oneJbrnt. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
AS-8 abandonment to the following:
Division of Water Quality,Information Processing Unit,
30.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Infection Wells: In addition to sending the form to the address in l0a
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:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 8'0 (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): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013