Pender_Well Abandonment_ (3)

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 t n lliple it jection or non-,rater .%apply irells ONLY with the saute
construction/abandonment,you can submit one form.
A - 4475
7b.Approximate volume of water remaining in well(s): 3'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 we//construction permits(i.e.County,State,lrariance,etc)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
i ultural ❑Munici al/Public ❑Neat Ceme t-GrouC _ ❑ Bentonite Chips or Pellets
❑Agr c p .
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) ❑ Sand Ceme,t F,1r¢uY ; S"i gi`L1•Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout 2'd Drill Cuttings
❑Irri ation ❑ SpecialtyGrouta•'JC 21122 ❑Gravel
Non-Water Supply Well: ID Bentoni esSlurry ❑ Other(explain under 7g)
RiMonitoring ❑Recovery r :M.•, .,'
Injection Well: 7f.For each material�selieZIG ibve,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 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
5a.Well location: _
JOHNSONS CORNER GRILL
Facility/Owner Name Facility lD#(if applicable) $•Certification: !/
9031 US - 421 CURRIE 28435 ��- 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
34° 27 27.25 78o 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 available. For nnthiple it jection or ran-,rater supply
u•etts ONLY with the.sante consirucuontabandonnie t.you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
AS-12 abandonment to the following:
Division of Water Quality,Information Processing Unit,
30.0 1617 Mail Service Center,Raleigh,NC 27699-1617
fib.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:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 5'0 (fl•) 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.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
i
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013