Yadkin_Well Abandonment_20220815 (2)

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" WELL ABANDONMENT RECORD For Intemal Use ONLY: f
1.'v)'Sjl Contractor Information: WELL ABANDONMENT DETAILS!
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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
wells abandoned:
NC well Contractor Certification Number u P� ' 7b.Approximate volume of water remaining in well(s): (gal.)
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YADKI N WELL COMPANY II N -�� FOR WATER SUPPLY WELLS ONLY:
Company Name + 7c.Type of disinfectant used:
2.Well Construction Permit#: p1�fJ i x
List all applicable well construction permits(i.e.UIC,County,State,[( nFq 1e d Z
�.tA, JOG. 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used.(check all that apply):
❑Agricultural ❑MunicipabPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 27 t,onfrete Grout ❑ Drill Cuttings
❑Irri anon ❑ Specialty Grout a-6ravel
Nbn-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection 1\'ell: 7f For each material selected above,provide amount of materials used: 1
❑Aquifer Recharge ❑Groundwater Remediation a 3 -�o DI
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage �oe>CrrC `r�( �d �a r ` U Iv`
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer fib(
❑.Geothermal(Heating/Cooling Return) 1 V�1) 0Other(explain under 7g) re �) PC 6V C,LC�� �
PO of q(k tl `�b �i`7 t (� q (9� -� Ci ll CIFF-
d.Date well(s)abandoned: �r z Z L'
s i by LA , Becow /�i rti.dQ. csp-m .,�k
5a.Well location:
Facility/Owner Name Facility ID9(if applicable) 8.Certification:
pbysi al Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
By signing this fonn, 1 hereby certify that the ivell(s) /vas (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 ouurer•:
5b.,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) G T� 9.Site diagram or additional well details:'
3(.- . N25V N U © �+ (� � 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
Attachx,ellcotrsintctiotrrecord(s)tjavailable.Fot•nrultipleinjectionornon-rvatersupplywells
ONLY with the same constntctionlabandonment,you can submit one fonn.
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10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well lD#: eA M '1 901 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 3 a 3 (ft.) 1617]flail Service Center,Raleigh,NC 27699-1617
1 r 10b.For Iniection Wells: In addition to sending the form to the address in loa
above, also submit one copy of,this form within 30 days of completion of well
tic.Borehole diameter: `i (in•) . abandonment to the following:
Division of.Water Resources,Underground Injection Control Program,
6.-d.Water level below ground surface: s.«•' (ft.) 1636 Mail Service Center,Raleigh,INC 27699 1636
loc.For Water Supply&Iniection Wells: In addition to sending the form to the
6,e,Outer casing length(if knolvn): —(fI) 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
6f.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