Moore_Well Abandonment_20221122

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
N&rma'h , . f►1 abe, 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having'tthe same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:_
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Company Name o a 4 m,
7c.Type of disinfectant used: z
2.Well Construction Permit#:
List all applicable well construction permits(i.e.01C.County:State,[variance,etc.)ii known N 0 V 2 2 2022
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appl`p
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑.Bcntonitc Chips or Pellets
❑Geothermal(Heating/Cooling Supply) We.idential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) 81/Concrctc Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
injection Well:- 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �x 4 Gl�l� Vart�S
❑Aquifer Storage and Recovery ❑Salinity Barrier /�dN
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer i w�-�—
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) aylD�r Ai P M /
e d � eCl
4.Date well .$)abandoned: 10 � Z 2—
5a.Well location:
Facility/OwncrName Facility ID#(ifapplicablc) 8.C�ertification:
3 1 " VVIurio llsgitl°tom . 1WfSf&4 AlG )7376 �=g .a6e
Physical Address,City,and Zip Signature of Certified Well Contractoror Well Owner Date
r►n By signing this form,I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02G.0100 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 p rovided to the well owner.
(if wc0 field,one lat/long 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.
CONSTRUCT16N.DETAiLS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavai/able.For multiple injection or non-watersupply wells
ONLY with the same construnctionlabandonment,you can submit one f orm. 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D# ? abandonment to the following:
�- Division of Water Resources,Information Processing Unit,
6b.Total well depth: © (ft) 1617 Mail Servickenter,Raleigh,NC 27699-1617
/h l0b.For infection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: "( (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: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (g) I0c.For Water Supply&lniection 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 Cif known): (D-) abandoned.
6g.Screen length(if known): (ft.)

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