Jackson_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: II WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
i Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number I L 7b.Approximate volume of water remaining in well(s): (gal.)
1 et'ra l:o n COnS U C�1 y �S /�I FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
{
2.Well Construction Permit#:
List all applicable well construction permits(1.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:
i
3.Well use(check well use): r
Water Supply Well: 7e. ahng materials used(checkiall that apply):
❑Agricultural ❑Municipal/Public VNeat 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
❑Irri ation ❑ Specialty Grout ❑Gravel
No - ater Supply Well: ❑Bentonite Slung ❑ Other(explain under 7g)
onitoring ❑Recovery
Injection Well: --- _ __ _ _---_ _-_ __ 7E.For:each material selected above,provide amount of-materials used:
❑Aquifer Recharge ❑Groundwater Remediation L O 'b
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer {,- ./e
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /^A`/YeJ I Calq J b � (
� )' ) /
4.Date well(s)abandoned: OCT )o Z az-
Sa.Well location:
(hers &VI-Y T'AC A+
Facility/Owner Name Facility ID#(if applicable) 8.Certify lion:
US l WlJt /v .Ifl a, V 8p �
f� (/ 3
Physical Addrress,City,anfl kip V Si cure of Certified Well Contractor or'Well Owner Date
��G`Ssy n By signing this form, I hereby cer{ify that the well(s) was(were) abandoned in
County Parcel Identification No.(PN 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavoilable.For multiple injection or non-watersupply wells .__. I__--_.
ONLY with the same c/o�nnstr-uc/tionla/b�andonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /vl W " V abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
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: t r (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
i
6e.Outer casing length(if known): (fL) 10c.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 1 health department of the county where
6f,Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): / D (ft)
i,
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I .