McDowell_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: 'WELL ABANDONMENT DETAILS
Bsei+ gurne I e, 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
Nll9'y _ A wells abandoned:
NC Well Coontralctor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
1 el-Noon 60/L SO 1 POA S -TA j, FOR WATER SUPPLY WELLS'ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(1.e.WC,County,State,Variance,etc.)if known
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 t4rlVeat Cement milt=- y yy u 4 �1)3entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout DEC 0 8 i 2022 ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
No Water Supply Well: ❑Bentonite SI�O'�'ri 3, 1 �'�. r, ..t OrOther(explain under 7
7 '_ (xP g)
onitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation .zq ,tom.
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experirirental Technology ❑Subsidence Control
7g.Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer y/Y
n t
A' /
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) NkCt Cabmen+ M:yet A, 1� �o'/
A�- /yl 6d6M►I' 0-F '\411 +o
4.Date well(s)abandoned:1�y 211 + 20 Z.2 L I
5a.Well location: A.A;W GapPeW 1n�� E©nG�'e��
G/06W reor- #L _Tne.* 7740
Facility/Owner Name U Facility ID#(if applicable) 8.Cc ation:
ILI-1'1-1 vs 2-21 A/0411 I 2Z�zz
Physical Address,City,and Zip SiKturlrof Certified We] ntractor or Well Owner Date
DL1/.0 I By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C 10100 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]atAon is sufficient) 9.Site diagram or additional well details:
G
'rJ tn�ly�
`St /d1� N You may use the back of this page to provide additional well site details or well W
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachwellconstrucdonrecord(s)ifavailable.For multiple injection or non-watersupply wells
OAZY with the same construction/abandonment,you can submit one form.
M 10a. For All Wells: Submit this form within 30 days of completion of well
/'1 6a.Well ID#• W— abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: O (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
r 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 ibis 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 tel nter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft-) 10c.For Water Sunoly&Infection 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
6E Inner casing/tubing length(if known): (ft.)
abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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