Pender_Well Abandonment_ (17)

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-,rater supply wells ONLY with the same
constructio✓abandonment,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#:
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 materials used(check all that apply):
❑Munici al/Public ❑ Neat Cement Gro t—',` ,•` ;a-BonWnite Chips or Pellets
❑Agricultural p ', -
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑ Sand Cement Grout 4 ?k O-Dv, Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout AUG 2� .Dd 20
Drill Cuttings
❑Irri ation ❑ Specialty GroutGravel
Non-Water Supply Well: ❑ Bentonite SlurrXny`;;;;;;,j_.:1 ;-)I;,_ ;3 :Ut apfth(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.25 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
El Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/1 1/22
Sa.Well location:
JOHNSONS CORNER GRILL
Facility/Owner Name Facility lDtt(if applicable) 8.Certification:
9031 US - 421 CURRIE 28435 C �" 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 ivell(s)ivas (were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0I00 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 lat/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 record(s)tJ'available. (or mulliple injection or non-water supply
wells ONLY with the some consiruciiorriabandomnrenl,you can submit oneJbrm• 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
MW-4 abandonment to the following:
Division of Water Quality,Information Processing Unit,
12.5 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: 4'0 (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. 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.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013