Pender_Well Abandonment_ (13)

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-water supply wells ONLY with the sonic
construction/abandonment,you can submit one form.
A - 4475 '
7b.Approximate volume of water remaining in well(s): 1.0 (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 well construction permits(i.e.County,State,Variance,etc.)iflcnown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing ma,q�ialSiised'(chec�C all+that°PRly):
Water Supply Well: y } _
❑Agricultural ❑Municipal/Public ❑Neat Cemen(Groin' Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gr,#I I D q 2�2� ❑ Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout h'J ❑ Drill Cuttings
❑Irri ation ❑ Specialty (Lut ,; a ' = :' F-Gravel
Non-Water Supply Well: ❑ Bentonite Slurry '" x ❑ Other(explain under 7g)
OMonitoring ❑Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.75 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 ID#(if applicable) 8•Certification:
9031 US - 421 CURRIE 28435 C.-r- �1 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER 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 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 78° 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
Anach well construction record(f)if available. 1%or multiple injection or non-water supply
wells ONLY with the saine construction/abandonntent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID/h MW-31 R abandonment to the following:
Division of Water Quality,Information Processing Unit,
Gb.Total well depth:
11.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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:
6d.Water level below ground surface: 8.0 (ft,) Division of Water Quality,Underground Injection Control Program,
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.
61:Inner casing/tubing length(if known):
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013