Pender_Well Abandonment_ (25)

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 ityection or non-water supply wells ONLY with the some
cons•truclionlabandonment,you can subtnit one form.
A - 4475 .025
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):
T.v
❑A ricultural ❑Municipal/Public ❑Neat Cerr}ent Grout- ;% 1 ,❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cenledt Gr.&, ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout�J� D 20rt� ❑ Drill Cuttings
❑Irri anon ❑ SpecialtyGro ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slu¢y."_1 '�;- :: Ur,p Other(explain under 7g)
❑Monitoring
❑Recovery L;11
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1.75 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)
4.Date well(s)abandoned: 08/1 1/22
Sa.Well location:
JOHNSONS CORNER GRILL
8•Certification:
Facility/Owner Name Facility,D#(ifapplicable) />
9031 US - 421 CURRIE 28435 z1f 08/16/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
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:
(ifwell field,one 1at11ong 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 well construction record(v)if arailoble. For nnttiple,ityec•tion or non-crater supply
wells ONLY with the same consiructioniabanclonuteiii,you call submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well[D#:
MW-29R abandonment to the following:
Division of Water Quality,Information Processing Unit,
10.0 1617 Mail Service Center,Raleigh,NC 27699-1617
Gb.Total well depth: (ft.)
10b. For Iniection 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
loc.For Water Supply R 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):
6g.Screen length(if known):
Fonn GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013