Hertford_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY: I
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1.Well Contractor Information: / WELL ABANDONMENT DETAILS
t^ l l✓__ /. 1! (,' 7a For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(r well owner pe-amlly abandoning well on his/her property) Well construction/depth,only 1 GWi 30 is needed. Indicate TOTAL NUMBER of
-30 L, wells abandoned
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NC Well Contractor 7fication Number 7b.Approximate volume of water,,remaining in well(s): S (gal.)
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!l 14M M G'S D h. �`!G. FOR WATER SUPPLY WELLS/ONLY: 1
Company Name 7c.Type of disinfectant used: Co Poe rt,x
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:; M14.1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑Sand Cement Grout ,'OM- ry Clay
❑lndustrial/Colmmercial ❑Residential Water Supply(shared) Concrete Grout ❑Drill Cuttings
❑Irrigation ❑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 (n ft C/�ti '�
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❑Aquifer Storage and Recovery ❑Salinity Barrier �s
❑Aquifer Test ❑StormwaterDrainage C2r+,2h� IY�r!✓` 0 .
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(expl ;rttsdtr,-79)a
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4.Date well(s)abandoned:
Z f 2 Z Dr C 0 55 2022 4 '
Sa.Well location: /
In','Crn;:4a--rl a (i$eL ,ah �-t W111 W4.J ttrhav,4 Gael
G;Jl" F DWQ;- )! G Cott CAP (Af/4
Facility/Owner Name ) Facility ID#(ifapplicable) 8.Certification: !ram
13�s- 4.S So,I M6 z7R ZZ A,,//. e, A,-L /Z-/ZZ .
Physical Address,City,and Zip a 1.� Signature o�fC8rtifiicd Well Contractor or Well Owner Date
�+��7 6r'(�t ���✓J,�—��b + By signing this form,I hereby cent y 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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrecshninuterdseconds a�decimal degrees: i
(ifwe/ll field,one latllong is sufficient) Q 9.Site diagram or additional well details:
N 0-7 0 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attaclrrcellcorrstructionrecord(s)ifavailable.For multiple injection or non-watersupplywells
ONLY with thesanie construction/abandonrnet:t,you can submit oneform.
— 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: 4 _(ft.) 1617 Mail ServiceCenter,Raleigh,NC 27699-1617
10b.For Iniection 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): t]t! m 1p� (ft.) 10e.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
/ r of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(If known): _(ft) abandoned.
6g.Screen length(if known): i t/ ri (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016