McDowell_Well Abandonment_ (3)

WELL ABANDONMENT RECORD " . For Internal use ONLY:
1.Well Contractor Information: 'WELL ABANDONMENT DETAILS
8re.i+ GurneA+ei 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 construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Hu p u - -A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of wati r remaining in well(s): (gal.)
1&T 400f) 60/!S y I IIP0 4,s TAG, FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ijlrnown i
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e. ling materials used(check all that apply):
❑Agricultural ❑Municipal/Public t�IVeat Cement Grout _ ; I ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement GrWf � � a y�O Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout _ ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout D C C O S 2022❑ Gravel
NoMWater Supply Well: ❑Bentonite Sluny. ❑Other(explain under 7g)
onitoring ❑Recovery 1rwoM—,3:1C1 Pr1,ca_. ;ng Ur;4I
Injection Well: 7E For each material sele,� a/O `] , ovine amount of materials used:
OAquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier V I ins gco
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer NW I. �yle/1 %1A:x@fYI �� p'V hl�
❑Geothermal eating/Cooling Return ❑Other(explain under 7g)
L-
4.Date well(s)abandoned: 1A&V 2' 20 2 Z LL
Sa.Well location: M011 bp)e- Gape ' W/ 40 I re-4
Ra/.6w *2- .zAc.;* -7740
Facility/Owner Name Facility ID#(if applicable) 8.Cc ' tion:
Iwrn Vs 1V &Or}'k ;w-,�� I I Z7-A
Physical Address,City,and Zip. S' ature of Certified Wel ntmctor'or Well Owner Date
ML�� C I I By signing this form,I hereby certify 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 degrees/minutes/secon s or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional Well details:
IS) �b /blot 1I&IaJ� i
W You may use the back of this page Ito 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
Altach well construction record(s)ijavailable.For multiple injection ornon-watersupplywells
ONLY with the same/c�ons9tru�ction/a/bandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID /►
#: /'1 W — U! abandonment to the following:
f�
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service iCenter,Raleigh,NC 276994617
10b.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: (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (fL) 10c.For Water Sunnly at Imecdori 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
K Inner casing/tubing length(if known): (fG) abandoned. i
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016