Pender_Well Abandonment_ (2)

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
in well on his/her property) For multiple itjection or non-+rater supply wells ONLY u•ilh the sane
Well Contractor Name(or well owner personally abandoning P P Y)
construcumhabondonm can.submit oneorm.enl,you f
A - 4475 .35
7b.Approximate volume of water remaining in well(,): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION F7d.Amount
ATER:disinfectant
PLY WELLS ONLY:
Company Name e of distant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknowm of used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Munici al/Public ❑ Neat Cement Grout f, .., ❑ Bentonite Chips or Pellets
❑Agricultural P I _ ? g
❑ Sand Cement br k, pis,. $ Fi d,,_•S_O Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) , Y',,�
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
c ❑ Gravel
❑Irrigation
❑ SpecialtyGroup,i�� �• a 202_
Non-Water Supply Well: ❑ Bentonite Slurry I p Other(explain udder 7g)
Monitoring ❑Recovery 7f.For each materia-sele'61`ali6ve,provide amount of materials used:
Injection Well'
❑AquiferRecharge ❑GroundwaterRemediation 5.0 GALLONS
❑Aquitier 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(,)abandoned:
08/11/22
Sa.Well location:
JOHNSONS CORNER GRILL
8.Certification: .
Facility/Owner Name Facility ID#(if applicable)
9031 US - 421 CURRIE 28435 C- � 08/16/22
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this form. I hereby cerlit that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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:
(if well field,one tat/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(,)iij'arailable. For ttmltiple itjection or non-water supply
wells ONLY with the same constructioniabandonment,you can.submit one fornt. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
AS-11 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 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:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 6'0 (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. 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.
61:Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013