Pender_Well Abandonment_ (15)

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 muhiple injection or non-water supply wells ONLY With the same
construction/abandonment,you can submit one form.
A -4475
A 7b.Approximate volume of water remaining in well(s): 5.5 (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)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing(rater also -
se .lcgak:fiII,t a pply):
❑Agricultural ❑Municipal/Public
❑ Neat Cem'enf Cfisut`"'' ""; ° '""' t❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ❑ Sand Cement r194t O fj 202
? ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout, i
❑ Drill Cuttings
❑Irri ation ❑ SpecialtM,,QSput};iD 1 'i;:?3c S 1 nt Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
l7lMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 6.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OExperimental 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#(ifapplicable) 8.Certification:
9031 US - 421 CURRIE 28435 �� 7 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this form,, 1 hereby cerlijy that the ivell(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
340 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 ivell construction record(s)ij'arailable. !•br multiple injection or non-[rater supply
,cells ONLY with the some consiructioniahandonnient,you con submit one form. 10a. For All Wells: Submit this fonn within 30 days of completion of well
6a.Well[D#:
M W-T1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
38.0 (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
6c.Borehole diameter: 2'0 (in•) abandonment to the following:
6d.Water level below ground surface: 5.0 (ft•) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection 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
6L Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013