Macon_Well Abandonment_20221014

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: IV G W 1R L' WELL ABANDOAtiVIENT DETAILS'
/na 1 ns 4i i 00h s eruva*4�o o �rf!US f 7a.For Geoprobe/DPT or.Closed-L'oop Geothermal WeIlshaving the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well constmction/depth,only 1 GW-30 is needed. Indice TOTAL NU1vMER of
wells abandoned:
at
_ I
NC Well Contractor CcrtificationNumber 7b.Approximate volume of water remaining in well(s): (gal.)
/V,C W" .{'o na-54 t.3 re Ir,h, FOR WATER SUPPLY WELLS ONLY: C-714L.�ahM1 s V t l^,
Company Name '
• G C�`r! �J 7a Type of disinfectant used:
OCT t2.Weli Construction Permit#: �( ✓5. y 7 ` - t5` 77 4
List all applicable well construction permits rL-UIC,Count,;State,Variance,etc.)rf/moivn
- 7d.Amount of disinfectant used: lsn`Y
3.Well use(checkwell use):
Water Supply Well:- 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout El Bentonite Chips or Pellets
Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ❑ Sand Cement Grout &,Dry Clay
01ndustrIal/Commercial ❑Residential Water Supply(shared) [DeConcrete Grout ❑Drill Cuttings
❑hri ation 0 Specialty Grout Graravel
Non-Water Supply Well: - ❑Bentonite Slurry ❑Other-(explain under 7g)
❑Monitoring ❑Recovery.
Injection Well: 7E For-each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Re.mediation
❑Aquifer Storage and Recovery ❑SalinityBarrier
[]Aquifer Test' ❑StotmwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
.❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7g) Due b —P Hoop eit0UAd CGSlh9 , Pma&,ed,
roD six Poet- d-F Ca. "l P , F,IN Lxl6f(i,c- ('OW .
4.Date well(s)abandoned:./&A z 2 a �
i,1t�4 Stone Concrt�e .Tht?e Co�� b Gr/r'1y Lit/
Sa.Well location:/YC L41 RC �l01 f a h CNPZtP bacti-Old *aCx13*f hp yaaae
MaIhg; _Seraggc
Facility/OwnerNamo T Faci ityID#(ifapplicable)_ 8.Certification:
5 7 G 5. l3rysy oh �. if y r-ran ) me
Physical Address,City,and Zip � g�3�.�' Signature ofCertified Well Contactor of Well Owner Date
A 42 ca n By signing this forth,I hereby certify.that the wells)was(were)abandoned in
County ]?arceI Identification No.(PIN') accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has be'emprovided to the well owner.
5b.Latitude,and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one.laUlong 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
abandonment-details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEL IG ABANDONED SUBNf WffAL INSTRUCTIONS
Auachwdlconstrucdonrecord(s)ifavaWle.For multiple injection ornon-watersuppiywells
ONLY with the same con bvetionlabandonment,yore tors 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-wyell depth: ! '� (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6ca Borehole diameter. (in.) 'above,also submit one copy-of this form within 3Q days of completion of well
abandonment to the following:
6tL Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27609-1636
6e Outer casing length(f known): (ft) 10c.For Water Suavly&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
6L Inner casing/tubing length(if known): (ft) abandoned
I
6g.Screen length Cif known): (ft.) I
Fomt GW-30 North Carolina Department of Environmental Quality-Division of Water Resotuees Revised 2-22-2016