Surry_Well Abandonment_20220919

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
�Lk'txt pgRTis�eSi f.LG' JAPuL DG�`uG /� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW;30 is needed. Indicate TOTAL NUMBER of
N6wells abandoned: _�Z_
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: �!/�/iC�a/.(�N " '� —a''4 fy
List all applicable tirell construction permits(i.e.UIC,County,State, Variance,etc.)ifknown 4 a �9 4 }
7d.Amount of disinfectant used:'
3.Well use(check well use): SEP !
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Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout In+uit?yt {b[�ufe C��t[f`$IOYJPfCs
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry di,
❑Industrial/Commercial ❑Residential Water Supply(shared) &'Concrete Grout ❑ Drill Cuttings
ORTigation ❑ Specialty Grout ❑ Gravel
Non- 'ater Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
onitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storm%ater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) &_Z xz b C% 'h 007— Nl At, (A �
.J �LJ�tI.tJEL�,D i:.c/� C/O'c7//JG LtfiTfi ZA�
4.Date well(s)abandoned: L. z .
'!4yG "c-401t-) /0
58.Well location:
Facility/Owner Name Facility IDL(ifappl cable) 8.Certification:
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Physical Address,City,and Zip Signature of Cer'fi d LL Contract`oror Well Owner Date
��rkR v l 9S/ 'S"(o 4310 -",Byhatch well(s) ry.��,e
signing this form, I hereby certify,that the as (were) abandoned in
County Parcel Identification No.(PIN) accordance with 154 NCAC 02G.O100 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:
(if well field,one)aUlong is sufficient) 9.Site diagram or additional well details:
N — , Quo 23O �, You may use the back of this page to provide additional well site details or well--
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF«'ELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the some construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: �t/� (tiJ —gam abandonment to the following:
2 Division of Water Resources,Information Processing Unit,
6b.Total well depth: 23 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: Z I (in.) above, also submit one copy of this form Within 30 days of completion of well
abandonment to the following: j
6d.Water level below ground surface: f Z (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Ui lK (ft.) 10c.For Water Suualy&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 1county health department of the county where
6f.Ioner casing/tubing length(if known): N (ft.) abandoned.
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6g.Screen length(if known): 7ir, 7CJ K `V (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016