Durham_Well Abandonment_20220909

WELL ABANDONMENT RECORD For lawmal Use ONLY:
1.Well Cmtractor Information: WELL ABANDONMENT DETAILS
7n.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well Contractor N e r well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 30 is needed. Indicate TOTAL NUMBER of
JftLa -1 to-7 —C, wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(,): (gaL)
CC �� FOR WATER SUPPLY WELLS ONLY: ((� y rA
Company Name J 1�„sp �� I �
7c.Type of dLsinfecfarmt used:—,�-�+v-}• q—
2.Well Construction Permit#:
List all applicable well evmbuction perndts(r.e.UIC,Cour tY,State,Panarm-,etc)ifltnown /
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mun�icipal/Public ❑Neat Cement Grout „ .* ,� ,❑ to Mips or Pellets
❑Geothermal(Heating/Cooling Supply) OR"id Water Supply(single) ❑Sand Cement Grout [sue n�)�c
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout S E P O 9 ,fit 1 Cuttings
❑lffi atie pecialty Grout
Non-Water Supply Well: ❑Bentonite Slurry IMofrA"Aon Pr.'%i; i.W,("lain under 7g)
❑Monitoring ❑Recovery 'D1, Q/B0G
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation r(AAXrAP DIA rr
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage V
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description f the abandonwmt procedure:
❑Geothermal(Closed Loop) ❑Tracer �l
❑Geothermal Heatin Conlin Return ❑Odmer lain under 7 )
4.Date well(s)abandoned:
Sa.Well location:
Facility/Owner N Facility MN(if applicable) 8 Certi ication:
O -4-,• L " /74 .2 2,
Physical Address,City,and Zip Signature of Certifi ell Contractor or Well Owner Date
050- f-31 -9q D By signing this form,I hereby certify that the well(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:
(if77weell field,one
elhlat/lonng�is sufficient) Q (� C( 9.Site diagram or additional weII details•
f 10 I _N P Vs-1 t W You may use 1he back of this page to provide'additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAIIS OF WELLS)BEING ABANDONED SIMMITTAL INSTRUC—ONS
Attach well consirncdon record(s)ifavailable.For multiple irgection or non-watersupply—Hs
ONLY with the same eonrtre don/abandomner4 you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion-of well
6a.Well ID#: abandonment to the following.
'blvisionof Water Resources,Information Processing Urdu f
°G17 Mail 3eivice Ceriter,;Rslelgll;iVC27699-1617 X.
6b.Total well depth _(ff-) s,
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e Borehole diameter. n) above, also submit one copy of ibis form within 30 days of completion of well
abandonment to the following:
6d Water level below ground surface (tt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known)• }t) 10c.For Water Samnly&Injection Wells: In addition to sending the form to 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
6E Inner casing/tubing length Cif Imown): g) abandoned.
ft Sonar length(i known): '" 1P, R)

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