Moore_Well Abandonment_20221205

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS i
Ea-PPAD GAA YA& 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 constniction/depth,only 1 tsyyteded. Indicate TOTAL NUMBER of
wells abandoned:_
NC Well Contractor CeditIcation Number 7b.Approximate volume of water remaining in well(s):• (gal.)
�Cr^ yw c(Z'T 0— FOR WATER SUPPLY WELLS ONLY: ("
Company Name
- ---- 111 --- 7c.Type of disinfectant used:
2.Well Construction Permit b:
List all applicable ivell construction permits(i.e.UIC,County,State,variance,eta)Ifknown
7d.Amount of disinfectant used: O Z
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M�unicipal/Public "eat Cement Grout I I�ntonite Chips or Pellets.4-r V�y
❑Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay ?t'P
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑-Bentonite'Slurry ❑ Other(explain under 7ei -
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of noteriats used
❑Aquifer Recharge ❑Groundwater Remediation rNY
❑Aquifer Storage and Recovery ❑Salinity Barrier Q r i Cz L.;
❑Aquifer Test ❑StormwaterDrainage LIP Del. 1) ;t. 29
❑Experimental Technology ❑Subsidence Control IL
7g.Provide a brief description of the abandonment p1Q dui•et+i � ?rt=^�
( c>❑Geothermal Closed Loop) ❑Tracer t1 tJ4;+;' i j
l7Geothernal(Heating/Cooling Return) ❑Other(explain under 7g) 14 usm- z 3r 1r�r,A i4 ego _ 4Z'
ff
4.Date well(s)abandoned: 'q
l' r.� ail ��t �ca,t••� _ �> 8 '`50'
5a.Well location:
Facility/Owner hame Facility ID#(if applicable) g•Cc
&7S D. Alp,) Ed . SOtA s Me-
,Z
Physical Address,City,and Zip �Q�8.7 gi Date
rtwo[t 33694 By signing this forghereiyrlify that the,veil( was(were)abandoned in
County Parcel Identification No.(PIN) 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:
Cif well field,one laVlong is sufficient) If
9.Site diagram or additional well details:
r��• Zh�O-1CJ Z N "�C��(���pz�,'� W You may use the back of this page to provide additional well site details or well
4 ! abandonment details. You may also,attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
uacii well construction record(s)Ifavailable.For multiple itliection ornon-watersupply wells
ONLY with the same constructionlabandomuem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
/f Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) ( 1617 Mail Service Center,Raleigh,NC 27699-1617
� I
Ile10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: (in.) above,also submit one copy of this form within 30 days of completion of well
r I abandonment to the following:
-t6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
't 1636 Mail Service Center;Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 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 health department of the county where
._Jt^6f,Inner casing/tubing length(if known);_ (ft,) abandoned.
i
6g.Screen length(if known): (ft.) i
1
Form OW-30 North Carolina Deparument of Environmental Quality-Division of Water Resources Revised 2-22-2016
t

I
1
. Lit ROL !.
6'
i
. � • r�•pir
.4.. n
_ e
. 4 w I •. '
i -
Y v '
I
I
i