McDowell_Well Abandonment_ (7)

WELL ABANDONMENT RECORD For Internal use ONLY:
1.Well Contractor Information: ,, 'WELL ABANDONMENT DETAIL'S
Bred+ g•usneA t,(_ei 7a.For Geoprobe/DPT or ClosedT4op 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
u p y A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water r maining in well(s): (gal.)
erNeoOn Gon S y ( hkA / xAc,, FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(1.e.U1C,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.%allng materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic eat Cement Gro•tt,-;:V r• 'F "'' r'IT Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Groutt` "t"'r "'° t hry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout D r C 0 18 202F Drill Cuttings
DIrri ation ❑ Specialty Grout ❑ Gravel
No Water Supply Well: ❑Bentonite SI-1Wbf�i�Dn t31i?C3 ap I er(explain under 7g)
Zi onitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 20 clq �'eJt.S �j�y7
❑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 �/ 1 1
❑Geothermal eating/Cooling Return) ❑Other(explain under 7g) Ncn (�Me��` A4.rXcrA 4t e/) pyAaPled
AL- 2� � �rom 6d��► �� MPell -�o fop
4.Date well(s)abandoned:1�1� 20 2
5a.Well location: M0AINO je, e_01 P i i/l4, l.DnG3'e��
Facility/Owner Name Facility ID#(if applicable) 8.Ce ation:
1�t'1�"I ys 221 �1/os}� 1 ZZ�ZZ
Physical Address,City,and Zip S' tore of Certified Wel ntractor nor Well Owner Date
&QDLIJC I I By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0'100 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 lat/lon�is suflicient)� , 9.Site diagram or additional w Ill details:
Si t'r A� t AG'�� You may use the back of this pagelto 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
Atiachwellconstructionrecord(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• /'l W — 12- abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
t 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy ofithis form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (fG) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (fk) 10c.For Water SUDDIV&Iniecti n 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):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resouri es Revised 2-22-2016