Wake_Well Abandonment_20220909

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor lUflornuitiont WELL ABANDONMENT DETAILS
L, do 6&2 7a For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(orwrAwncr personally abandoning well on hislher property) well constructon/depth,only i GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7h Approximate volume of water remaining in weIl(s): (gal)
Y SeS1�I Ce1
company FOR WATER SUPPLY WELLS ONLY:
—�— �� lc.Type of disinfectant used:
2.Well Conshnxilon Perndt#:
1,1
last all applicable well construction perrtdts Aa wa County,Stata Yadancq eta)ifltnown 7d.Amount of disinfectant used: tl`� e
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipwPublic ❑Neat Cement Grout ®;"� a❑Bentonite(hips or Pellets
❑Geothermal(Heating/Cooling Supply) t�?Ifsidential Water Supply(single) ❑ Sand Cement Graft y p t �"DnUttirigs
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑ e Grout ('F
❑Irri ation �'Bpacialty Grout `�-P o 'uuavel
Non-Water Supply Well: ❑Bentomte Slurry I�j,;,�;j � pr, Other(explain under 7g)
tiq
❑Monitoring ❑Recovery D'tftZ'ts
Injection Well: 7L For each material selected above,p,Qv%e amount of materials used:
OAquifer Recharge ❑Gtoundwatex Remediation Oct ,l; �1,,^ �`,��
❑Aquifer Storage and Recovery ❑Salinity Barrier �i
❑Aquifer Test ❑Stormwuter Drainage �e--
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 11
L4
❑Geothermal Heating/Cooling Return ❑OUter lain under 7 ) ( A
4.Date well(s)abandoned: d ol S C
5a.Well location (/
L&. cz� � rnlayl�
Facility/Owner Name -r Facility IDH(if applicable) &Ce catt0
k V ".) Grttt"s P& , -U� I 1 69, 0 fqA , 4,
Physical Address,City,and Zip �- �7`rjy'J9 S' lure Comma of Certified We r r ell Owner Da
SAL&S D ` / T By Mg_ng this form,I hereby cenV5,that the well(s)was(were)abandoned in
City Parcel Idemification No.(PIN) accordance with 1 SA 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 dgpws/n®mtes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
•� N ��� ( � W You may use the back of this page to provide additional well site details or well
u abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUIRMTTAi.INSTRUCTIONS
Attach well construction record(s)ifamlable Formulhpleiryechonornon-watersupplyw+efls
ONLY with the same con owaonlabandonment you can subrmt one form 10a. For AD Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following
.�Nn�� as•"rT-w.+��, trlri e� C�'`'��� �.",F.�`�1E'i nrt��
17
on of�Vater Resourceev',LBfor�natton+Processing Umt,
F!,�'�11617Mai1SYer4ice'}Ce1t,Ral�eigl,�NC27699s161SF
6h Total well depth: AL)
10h For Injection Wells In addition to sending the form to the address in 10a
6c.Borehole diameter: __(m) above, also submit one copy of ibis form within 30 days of completion of well
abandonment to the following
6d.Water level below ground surface70 (ft.) Mvhsion of Water Resources,Underground Injection Control Programs,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known) g,) 10c.For Water Suauly&Infection 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
6f:Inner casing/tubing length Cif known): 4, ft.)
abandoned
6g.Screen length(d known): N R)

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