Swain_Well Abandonment_20220930

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: '° "
^�'..s21� ^ ii....i .1.� h rn�• WELL ABANDONMENT DETAILS
n 0 11 j3 ft A"� r,�„ 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name for well owner personally abandoning well n h /h rdpe — well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
In;3s-,@ ;n P. Y.:,uj;;^:3 Ur;;
NC Well Contractor Certification Number 1-;' ui i::�C-: 7b.Approximate volume of water'remaining in well(s): (r L1 (gal.)
j CR fz y FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: M I A
List all applicable well construction permits(i.e.UIC County,Slate,Variance,etc.)ifMmwn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.>ealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
vKionitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
— a,JZ
❑Aquifer Storage and Recovery ❑Salinity Barrier n
El Aquifer Test ❑StormwaterDrainage �' f�i �� 886S 01- 1 oa7 l—A-0j0 Canla0r—
❑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) C,Q#J CaC—T45 0611 PAD AND W L IlVA,,,.-r IZc/PItAJea�
Q I Tt=�entZ PIPS PLAct:;,� j0 30TTOM or- vJ '
4.Date well(s)abandoned: —`-a a 0 a
NI&AT C_cMaSIT F,ticp t.JGI-- Firin.n f,3oMwl TO
5a.Well location:
A S t rrl•Lt�2. �t3t2FAC�. PYj ATEiLt A L. Ft M�slac3n aT Tc��
Noi Spo: 1102 0-0-0000003Z113
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1030 MA,NJ STilC'ET , 82y5011 C.1T! 202a
Physical Address,City,and Zip Signature of Certi d Well Contractor or ell Owner Date
C�►/'�4d 0 Q���Q
1 /..� 7/� By signing this firm, I hereby c•erlify that the well(s) was (were) abandoned in
Countv 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.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat long is sufficient) 9.Site diagram or additional well details•
3d• q 3 19(D y N &3, q 3 Z 3 W 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well c»nsu•uctian records)ifarailable. For multiple hyection or non-irater supply xelLs
ONLY with the same caostructian/abandanmenl,you can submit one fbrru.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: Itil ' I abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: C) (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
^ 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. d (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- 9.0 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): —7• (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this farm within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): NIA (ft.) abandoned.
6g.Screen length(if known): l o• o (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016