Watauga_Well Abandonment_20221014

WELL ABANDONMENT RECORD
For�Intemal Use ONLY: ` i✓ �� r'+
This forth can be used for single or multiple wells OCT
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I.Wcll Contractor Information: WELL ABANDONMENT DETA i'S
a ' r u w n 7e.Number of wells be
abandon id: `'��' "`✓r t/if
:Well Contractor Name(or well owner personally abandoning well on his/her property) For mulriple injection or non-water JuPply welts ONLY wide the some
3 V`�'1 construcuon/abandonmem.you can submit'one form.
NC Well Contractor Certification Number I 7b.Approximate volume of water remairifng in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 14.11-1
2.Well Construction Permit#:
List all applicable well construction permits(t.e.Coun(,State,Variance,ere.)If htoxn
7d.Amount of disinfectant used: Jo d
31 Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑ untclpal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) AVesidential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) O Concrete Grout ❑Drill Cuttings
❑Irri ation O Swecialty Grout [}caravel
Non-Water Supply Well: Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L'For each.material selected above,1:provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Vot
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide it brief description of the procedure:
,abandonment dure:
pp �
❑Geothermal(Heating/Cooling Return) ❑Other explain under 7 — 0 ���wl �'ra
4,Daic rvell(s)abandoned: C / yA' ^ aA
Fl (Z,,C t' 2 le-
5a.Well location:
•Facility/Owner Name Facility lDH(ifappliceble) S.Certification:•
Physieal-Addre11s3,City,and Zip Sigr�atum of Certified Well Contractor or Well Owner Date
fA°C�ny\.f By signing this form, I hereby certl that the well(s) was were bandoned in
County Parcel Identificetion No.(PIN) accordance with 1 SA NCAC 01C.0100.or 2C.0200Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been,prorided.ta the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
-7rs 7N B-q -1) 3 Q You may use the back of this page toyrovide additional well site details or well
W abandonment details. You may also attach additional pages if necessary,
CONSTRUCTION DETAILS OF WE L( i BEING ABANDONED SUBMITTAL INSTRUCTIONS.Attach well construction record(sj jm,ailable. For multiple Injection or non-water supply
wells ONLY with tltesame construction/abandonmenr,you can submitoneform. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Quality;Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
t
r 10b.For Ioiection Wells: In addition,to sending the farm to the address in l0a
6c.Borchole'diameter: �(J (in,) above,also submit one copy of this to'rm'within 30 days of completion of well
abandonment to the following:
6d:Water level below ground surface: �- (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Sci•vice Center,Raleigh,NC 27699-1636
6e.Outcr'casing length(if known): -{ (p (ft.) loc.For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, als6 submit one(copy of this form within 30 days of
completion of well abandonment to the county health department of the county
.6f.Inncr casing/tubing length(if known): (ft.)
where-abandoned. s
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water a
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' tY . Revised March 2013