Pender_Well Abandonment_ (10)

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 multiple injection or non-scaler supply wells ONLY a ith the some
consiruction/abandonnient,you can submit one form.
A - 4475 1.0
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:
2.Well Construction Permit It:
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Munici al/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Agricultural P .
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cerri G[4uf`1 g Dry Clay
y, >" -:� s 1 _. 21
❑Residential Water Supply shared ❑ Concrete Vr011i— ❑ Drill Cuttings
❑Industrial/Commercial PP Y(shared)
❑Irri ation I-
❑ Specialty Grout'J(�1 I 1 2 2022 ❑ Gravel
Non-Water Supply Well: Ri Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring
❑Recovery If1iCit >`;? :1 �f•'. >s Y.;; Ural
7f.For each material.se[EetSd:�a�pve,provide amount of materials
Injection Well: used:
❑Aquifer Recharge ❑Groundwater Remediation 2.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothennal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
08/11/22
Sa.Well location:
JOHNSONS CORNER GRILL
Facility ID#(ifa livable) 8•Certification:
Facility/Owner Name Y PP
9031 US - 421 CURRIE 28435 C - 08/16/22
ell Owner Date
Physical Address,City,and Zip Signature ofCertified Well Contractor or W
PENDER By signing this form, I hereby verb that the ivell(s) ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Consiniction 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
27.25 780 03' 02.30" You may use the back of this page to provide additional well site details or well
34° 27
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach we//construction record(s)if available. For multiple injection or non-waier supply
wells ONLY with the same construction/abmulonnteni,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well iD#:
MW-30 abandonment to the following:
Division of Water Quality,Information Processing Unit,
12.0 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
6e.Borehole diameter. 2'0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 4.0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc.For Water Supply&Injection 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.
6L Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
i
Form G W-30
North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013