Pender_Well Abandonment_ (24)

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 it jection or non-[rater supply wells ONLY will; the some
c•ons•iructiordabmrdonnnew,you can subnril one form.
A - 4475 10
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,Stale,Variance,etc.)ij'knou'n 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Munici al/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Agricultural P » "1' '•
❑ Sand Cement OFrbu'"'„ — f`n'L Dry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Zw,,3._r a 4. '1 ., .••
1 shared ❑ Concrete Grout '� "" ❑ Drill Cuttings
❑Residential Water Supply PP y(shared)
Olin' ation ❑ Specialty Grout pi��, ❑ Gravel
Non-Water Supply Well: � Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery ��; z-
Injection Well: 7C For each ma�rtal selected A bo,AE provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2.0 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)
d.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
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
PEN DER By signing this form, l hereby certify that the ivell(s)ivas (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0I00 or 2C.0200 Well Construction Standards
and thal 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:
78� 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 c•anrsirucaorn record(.+)if available. For multiple injection or non-water.supply
wells ONLY wilh the.same construction/abandonment,you can subnril one form. 10a. For All Wells• Submit this form within 30 days of completion of well
6a.Well ID#:
MW-28R abandonment to the following:
Division of Water Quality,Information Processing Unit,
12.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Injection Wells: In addition to sending the form to the address in l0a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (itt•) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: $'� (ft•) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection 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 GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality
Revised March 2013