Wake_Well Abandonment_20230104

WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David E. Meyer 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 OW-30 is needed. Indicate TOTAL NUMBER of
2527—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name n
2.Well Construction Permit#:
G V V-090966-2022 7c.Type of disinfectant used:
List all applicable well construction permits O.e.UIC,Counh,,State,Variance,e1c.)ifknrruu i 1 2 oz.
7d.Amount of disinfectant used:,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agneultural ❑MunicipaVPublic a Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑.Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
[]Monitoring ❑Recovery -
Injection Well: f {�'S '°� { �
I 7f.For each material selected above,provide amount of�te(�ia�l�u�h� a � y
❑Aquifer Recharge ❑GroundwaterRemediation 150 gallons
❑Aquifer Storage and Recovery ❑Salinity Barrier z on
ifAli _ 23
❑Aquifer Test ❑Stormwater Drainage I
❑Experimental Technology ❑Subsidence Control acm PrL—,-5zV,-n-g�G'1
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procc ure: ry+w;iQJfw
❑Geothermal(Heating/Cooling Return) ❑Other(explainunder7g) Well sounded found free of obstructions
chlorinated,filled with neat cement grout to surface
4.Date well(s)abandoned: October 25,2022 t
well pad and top 3. casing removed
Sa.Well location: brought back to original grade
John Karmire na
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
7317 Rocky Ridge Road Wake Forest NC 27587 _ 10/25/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 1850875938 By signing this Jorm, I hereby cell ,that the ivell(s) was(were)abandoned lit
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 Well Consmiction Standards
and that a copy of this record has them provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
35J58t 09.156" N 78�27t 49.381 tt `,(, 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
Altacbtcellcoastructionrecord(s)ifavallable.Forvnulliple injection ornon-watersupplvnrils
ONLY with the same cmhstructia✓abandonment,you can submit one fora[, r
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#• g�
• Division of Water Resources,Information Processing Unit,
6b.Total well depth: 305 (fL). 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to.scnding the form to the address in 10a
6c.Borehole diameter• 6.5 (in,) above,also submit one copy of thisifonn within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface• 50 (ft.) Division of Water Resources,iUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):46 (ft.) 10c.For Water Suonly&Iniecti I n Wells: In addition to sending the form to the
addresses)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): 50 (l i n e r) (f�) abandoned,
6g.Screen length(if known): n a
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016