Johnston_Well Abandonment_20221205

WELL ABANDONMENT RECORD IFor Interrml Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Don Byrd (Owner of Property) 7a.Number ofwells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction/abandonment you can sub nd one form
7b.Approximate volume of water remaining in well(s): 50 (gal.)
NC Well Contractor Certification Number i
FOR WATER SUPPLY WELLS ONLY:
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Company Name 7c.Type of disinfectant used Chlorine tablets
2.Well ConstructionPerntit#: Johnston County- 190341
List all applicable well permits(ie.County,State Variance,Injection,etc.)if known 7d.Amount of disinfectant used'' 1/2 a box
3.Well use(checkwell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipwPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
[]Geothermal(Heating(Cooling Supply) EIResidential Water Supply(single) ❑Sand Cement Grout �, 0 Dry Clay
❑Industrial/Commercial ❑Residential 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: 7E For each material.selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Dry Clay 2 yards
❑Aquifer Storage and Recovery []Salinity Barrier Concrete 2 yards
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Removed pipe and pumps. Removed concrete
❑Geothermal eatin Cooling Return ❑Other(explain under 7
a` ��wall around well. Poured concrete in well and then
11/23/2022 � - � a' `�� bt r..:
4.Datewell(s)abandoned: _ clay until it was level with the ground
5%Well location: r C L 2�2Z
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Don Byrd
Facility/Owner Name Facility ID# —S.Certification:
1700 Block of Parker Rd Four Oaks l i' 17 Z� Za2Z
Physical Address,City,and Zip Si ture of C ed Well Contractor of Well Owner Date
Johnston 08H10076A
By signing this form,I hereby certify that the wells)was (were) abandoned in
County Parcel IdentificationNo.(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:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For-mulliple injection-or non-water supply
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.Wel[HW: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (tit) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
24 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter. (in.)
abandonment to the following:
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6d.Water level below ground surface: 25 (g) Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
10c.For Water Sunnly&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (fL) 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
6f.Inner casing/tubing length(if known): (tt.) where abandoned.
6g.Screen length(if known): (tY)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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