McDowell_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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D red' 13 V rn e,4e 7a.For Geoprobe/DPT or Clos Id-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW730 is needed. Indicate TOTAL NUMBER of
Q �L wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Ter ra con FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.)ifknawn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.SS ling materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0/Neat Cement Grout i ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grgut��t Al a' V 1El9DD Clay
❑IndustriallCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
[]Irrigation ❑ Specialty Grout DEC 0 .8 2022❑ Gravel
Non-Water Supply Well: ❑Bentonite Sl Q Other(explain under 7g)
❑Monitoring M4covery Vi nrr irn P}imc; j- u
Injection Well: 7f.For each material selec et(aDoove,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 35 561� C�
❑Aquifer,Storage and Recovery ❑Salinity Barrier CC I q
❑Aquifer Test ❑Stormwater Drainage •.7x �l�
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer f
❑Geothermal(Heating/Cooling Return) ❑Other explain under 7g) 1�1
R1� b44om ©� wol 1 0 , ' op
4.Date well(s)abandoned: Nov r ,
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5a.Well location: _
Rctr�bow Pta.��•1•u '# 2 xnG* 7760
Facility/Owner Name Facility ID#(if applicable) 8.Cc r'fieation:
ly•1-r-7 /INar'}� lJ 22 2 2
Physical Address,City,and Zip Signature of Certified Well 6Atractor or Well 0,*mer Date
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By signing this form, I hereby ceiitify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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/seconds or decimal degrees:
(if well field,one tat/long is suffigeliv MQj'^ -0&JVdCJ 9.Site diagram or additional wells details:
►GN 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 well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with 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#: R W abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service C enter,Raleigh,NC 27699-1617
u10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: I (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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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): (fL) lOc.For Water Sunnly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one c 11 opy of this form within 30 days of completion
of well abandonment to the county health department of the county where
611 Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016