McDowell_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For Internal use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
r8re 1T purf%eA 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
H4 p y A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CTS'c1Gon 6,04 S✓ I J j,Gk �S -TAO, FOR WATER SUPPLY WELL'S 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.)iflmown b
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7;e`�ealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public eat Cement Grou r-a a ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grou I �y�t�crG"-Dlay
. e,; : r
❑lndustrial/Commereial ❑Residential Water Supply(shared) ❑ Concrete Grout _ �pp ❑Drill Cuttings
❑hri ation ❑ Specialty Grout DEC `V 8 2022 Gravel
No Water Supply Well: ❑ Bentonite Slurqf., Other(explain under 7g)
onitoring ❑Recovery
�'��i_ i'
Injection Well: 7f.For each material selecte a°bo�ve,�ravide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ?y ,q q J h%-S �(S'U
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) (/��t'c,,C4� C&Mefl+ M•.,ye"" en �V pl""
Troll bd �y► O� pyl I 40 �op
4.Date welt(s)abandoned: 1 AL_�y 2 � Zd 2 Z � �°t •�{�,�M M,f
5a.Well location: AWbo)e_ Ga�Pe� wl),� ConG1'e4e-
Ram ow Pang *2- -TA.-,;* -7740
Facility/Owner Name Facility ID#(if applicable) 8.Cc ' ation:
!Lf111 VS Z21 Nos'} 1 14,Z�LZ
Physical Address,City,and Zip. S.
lure of Certified We] ntractor or Well Owner Date
i�G®b>✓1/G ' ' 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:
(if well field one latllong is sufficient) (
_ , 9.Site diagram or additional well details:
Si o Ma rnrlvr�
N W You may use the back of this pagelto 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
Attachwellconstructionrecord(s)ifavailable.Formultiple injection ornon-watersupplywells
ONLYwith the same construction/abandonment,you can submit one form.
�/► 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• /'1 W— abandonment to the following:
J/'�� Division of Water Resources,Information Processing Unit,
6b.Total well depth: V (ft.) 1617 Mail Servickenter,Raleigh,NC 276994617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2- (in.) above, also submit one copy of thfi 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 ServiceiCenter,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Iniectioit 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 country health department of the county where
6E Inner casing/tubing length(if known): (fC) abandoned. I
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourc I es Revised 2-22-2016