McDowell_Well Abandonment_ (5)

WELL ABANDONMENT RECORD For Internal use ONLY:
1.Well Contractor Information: ,, 'WELL ABANDONMENT DETAILS
Bral+ gurne tj e, 7a.For Geoprobe/DPT or Closed-Lo p Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only l GW.30 is needed. Indicate TOTAL NUMBER of
l y A wells abandoned: I III
NC Well Contractor Certification Number 7b.Approximate volume of waterlrehiaining in well(s): (gal.)
erNe'on 004 s u I foln h -TAO, FOR WATER SUPPLY WELLSIONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: j;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifkmown
7d.Amount of disinfectant used:
3.Well use(check well use): j
Water Supply Well: 7e.§ealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public W9 eat Cement mot , .. o TM� ❑Bentonite Chips or Pellets
R Ppi S.-�,.,q
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement • ut-- .o� ; f� �' ii1 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout D F �. []*Drill Cuttings
❑lrri ation ❑ Specialty Grout 0 8 2022 ❑Gravel
ZWater Supply Well: ❑Bentonite SlfiWrv:,!3--,1 , it ]!P,Other(explain under 7g)
nitoring ❑Recovery ;;t e•'; GOG .
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7 rid"jl mr C rd Ji
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
[]Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of;the abandonment procedure:
A`en l CaMe4 �rXCA A e/l nv�/9�
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ,1' �i' N
61y, A,dtet! +o fop
4.Date well(s)abandoned:1 A/ay 21 + ZD 71 z
5a.Well location: P611;1 j)g GQl�i4eisl �,✓�xn CpnGf e��
�arnbow pai� 'r #'2. SAC. 7T(o0 tt--rr
Facility/Owner Name U Facility ID#(if applicable) S.Cer' ation:
14-11-1 us 2_21 A/or},k A ' 1 A z A-z-
Physical Address,City,and Zip. S' tur of Certified Wel ontractor'or Well Owner Date
.MLDow.e 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 latllopg is sufficient) , 9.Site diagram or additional well details:
`St G ', N 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 if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconsiructionrecord(s)kfavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
/�/►'-I 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• /'1 W — abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service i Center,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): 00 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit orie copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (fL) abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Reso I esl Revised 2-22-2016