Pender_Well Abandonment_ (18)

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
For multiple itjeciion or non-crater supply Wells ONLY Will? the s'anre
Well Contractor Name(or well owner personally abandoning well on his/her property) consiructionlabandonment,you can submit one form.
A - 4475 0.25
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 Grout ❑ Bentonite Chips or Pellets
❑Agricultural p —.p r= ^®^dry Clay
❑ Sand Cement Gr6uY' u 1= i
❑Geothermal(Beating/Cooling Supply) ❑Residential Water Supply(single) r r 0, r❑Drill Cuttings
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout g
❑ Specialty Grout AUG
r D `� 2022 ❑Gravel
❑Irv- anon Y J l� ❑Other(explain under 7g)
Non-Water Supply Well: � Bentonite Slurry ( p
❑Monitoring ❑Recovery In`'C.S.t > C r'? = '" Ul:ii
7C For each maferta(se{le�led�aho�v provide amount of materials used:
rEDAquifer
ction Well:
uiferRecharge ❑GroundwaterRemediation 1.75 GALLONS
Storage and Recovery ❑Salinity Barrier
qufer 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:
08/11/22
5a.Well location:
JOHNSONS CORNER GRILL
8.Certification:
Facility/Owner Name Facility ID#(if applicable)
9031 US - 421 CURRIE 28435 - 08/16/22
Signature of Certified Well Contractor or Well Owner Date
Physical Address,City,and Zip
PENDER By signing this form, 1 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one lat/long is sufficient)
780 03' 02.30" You may use the back of this page to provide additional well site details or well
340 27' 27.25" 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)if available. For multiple injection or non-Water supply
Wells ONLYWith the same construction/abandonment,you can submit oneJorm• abandonment to the Following:
a. For All Wells Submit this form within 30 days of completion of well
6a.Well ID#:
MW-18 aba
Division of Water Quality,Information Processing Unit,
10.0 1617 Mail Service Center,Raleigh,NC 27699-1617
61i.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: 8.0 (ft.) 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
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
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