Pender_Well Abandonment_ (20)

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-crater supply sre/Is ONLY with the some
( P Y g construction/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 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(t.e.Cowny,State,Irariance,etc.)iflcnowii 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Agricultural ❑Municipal/Public an IV—%
❑ Sand 0"] ent" oul ='" y ❑ Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) F{:, r' ❑ Drill Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete G w
❑ Specialty Gr IIJ(� D co2�2�. El Gravel
❑Irri ation J ❑ Other(explain under 7g)
Non-Water Supply Well: ❑ Bentonite S urry ,�UrrlI
❑Monitoring El Recovery ;^' qyg •.:,.bo
Injection Well: 7f.For Al Ffinatersials�lgS �"above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 2.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aqui fer Test ❑Stor nwater 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 lD9(if applicable)
2 '.
9031 US - 421 CURRIE 28435 �- J' 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PENDER By signing this fornt, I hereby certify that the ivell(s)was (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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Site diagram or additional well details:
(if well field,one lat/long is sufficient) g
7$0 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)ifarailable. I•hr nulitple uyecnon or non-crater supply
we/Is ONLY with the same consiroctioir/abanclonutent,you con submit one form. IOa. Far All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
MW-23 abandonment to the following:
Division of Water Quality,Information Processing Unit,
12.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (tt.)
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: 7'0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunaly&Infection Wells: In addition to sending the form to
6c.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 OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality
Revised March 2013