Pender_Well Abandonment_ (7)

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 mulliple h jeclion or non-water supply wells ONLY with dte sume
construction/abandonment,you can submit one form.
A - 4475 � 2,0
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:
i
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,Slale,Variance,etc.)ifknown 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 T c o m ❑ Bentonite Chips or Pellets
olingSupply) ❑Residential Water Supply(single) ❑ Sand Cement{ out", ' 1 ❑ Dry Clay a,2 ;❑Geothermal(Heating/Co Co , Y,❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout AUG D. , 202? ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitorin ❑Recove
g ry Injection Well: 7f.For each material provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.75 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquiter Test ❑Stormwater Drainage
❑Experimental Technology El 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)
d.Date well(s)abandoned: 08/11/22
5a.Well location:
JOHNSONS CORNER GRILL
Facility/Owner Name Facility ID#(ifapplicable) 8•Certification:
9031 US - 421 CURRIE 28435 �� -r_ J 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 well(s)ivas (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 27.25 780 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach well coustr ction record(s)if arailoble. For multiple byection or non-realer supply
wells ONLY wilt rile same construclion/abandonntent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
AS-23 abandonment to the following:
Division of Water Quality,Information Processing Unit,
29.01617 Mail Service Center,Raleigh,NC 27699-1617
fib.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:
17.0 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&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.)
6g.Screen length(if known): (ft.)
Forth G W-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013