Pender_Well Abandonment_ (8)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
L CARPENTER 1
CAR 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple hyeclion or non-haler supply wells ONLY with the same
constructionlabandonmem,you can submit one form.
A - 4475 5.3
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,I'ariance,etc.)iit known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Munici al/Public ❑ Neat Cement gr,roui'�' - Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement`Grbulf ' ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ��1(� � 20ZZ ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout J ❑ Gravel
Non-Water Supply Well: ❑ Bentonite S r H 6her(explain under 7g)
a,
OMonitoring ❑Recovery
FDAquifer
ion Well: 7f.For each material selected above,provide amount of materials used:
Recharge ❑GroundwaterRemediation 5.0 GALLONS
ifer Storage and Recovery ❑Salinity Barrier
ifer 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 ID#(if applicable) 8.Certification: -
9031 US - 421 CURRIE 28435 � 7 l � 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this form, /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 ivell 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° 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 recorcl(s)if orailable. For multiple u jection or non-water supply
wells ONLY with the same construction/abandonment,you cat;submit one forme 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
AS-21 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 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 (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supoly& 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.
6f.Inner casing/tubing length(if known): (ft.)
i
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013