Person_Well Abandonment_20221118

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
go AJW / � �, ___01 � 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 I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b,Approximate volume of water remaining in well(s): 3d _(gal.)
1319AA.. -f-e w e o zrL%1 fice_ FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 7?4l
2.Well Construction Permit#: S 6
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ijbiotvn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling,Su*ly) ORzestdential Water Supply(single) L-Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial Elggsidential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply'Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier n
❑Aquifer Test ❑StormwaterDrainage y/:.I-2�5/"IL)
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer n n
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) G u-t C I '2GJ e h!P'Q.'
f o o-F H d l e wr4;1,
4.Date well(s)abandoned: Zo "
5a.Well location:
Facility/ ner Name Fa lity ID#(if applicable) 8.Certification:
p e _
76 I�nt t )231<A i.0 kk � ���� .Lr. �� to -1.3-"Z 2
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
t('e S fl x By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
t!l You may use the back of this page to provide additional well site details or well
3'7 2 6 N 7 S� - 5 Q W
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recm•d(s)ifavailable. For multiple injection or non-watersupply 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#: 96 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: sU (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6r�{ above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 3 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Z 6 (ft.) I Oc.For Water Supply&Iniection 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
61.Inner casing/tubing length(if knownn)� �OJ`�L (ft.) abandoned.
6g.Screen length(if known): (/"t/l� (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016