Rowan_Well Abandonment_20220930

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WELL ABANDONMENT RECORD For Internal Use ONLY: r
1.Well Contractor Information:L, WELL ABANDONMENT DETAILS
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 J GW 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
(450 - C
NC Well Contractor Certification Number 7b.Approximate volume of water iremaining in well(s): (30 (gal.)
1 ' t C( m �� P FOR WATER SUPPLY WELLS!ONLY:
Compdny Nam`
7c.Type of disinfectant used: Chlar Mt
2.Well Construction Permit#:
List all applicable well construction permits(i.e. UIC,Counr,State, Variance,etc.)iflrnown q 2 1 d.Amount of disinfectant used:
3.Well use check well use): sf "
Water Supply Well: Y c' P 202� 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M icipal/PuI E• 3 11 ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 133tesidential Water.Supply,(sjngh}'• 'Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residen �,.
}i�l'4Vater Concrete Grout ❑ Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 70
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 45
ilflf�s
❑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 n (�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Q y, e Q `i1�11�i<!v� k GYX< •C+l,G 4 p
4.Date well(s)abandoned: -
5a.Well location-
Facility/Owner Name Facility ID#(if applicable) 8.Certific 'on:
Ph ical Address,City,and Zip Sign of Certified ConV
11 Owner Date
oWay', B igning this rm, 1 erethat the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) ¢ecordance with CAC or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
1 �f / You may use the back of this page to provide additional well site details or well
N O " h W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: Q5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: H (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: d (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 7C (ft.) 10c.For Water Supply&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
6f.Inner casing/tubing length(if known): X (ft.) abandoned.
6g.Screen length(if known): /K
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