Wilson_Well Abandonment_20220531 (4)

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply tivells ONLY with the same
C -4421 constructionlabandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): 3.25 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ij'known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement ut - ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grote U 5a E- Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
MAY 3 1myry
Non-Water Supply Well: IZI Bentonite Slurry 20L2 ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 711 For each rQeifial�ele�ie�d�boi :lfY� ount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
[]Geothermal(Heating/Cooling Return) 00ther(explain under 7g)
4.Date well(s)abandoned: 04/04/22
-5a:Well location: j
KORETIZING CLEANERS
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1313 WARD BLVD WILSON 27893 �"`��'a'"'"` 04/20/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
WILSON By signing this form,I hereby certify that the ivell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well details:
350 43' 09.99" 770 56' 10.80" You may use the back of this page to 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
Attach well construction record(s)if available. For multiple injection or non-water supply
ivells ONLY with the same constructionlobandonment,you can submit one form. 10a. For All Wells: Submit this,form within 30 days of completion of well
6a.Well ID#: M W-7 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 5.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department ofEnvironment and Natural Resources-Division of Water Quality Revised March 2013