Harnett_Well Abandonment_20230112

II
WELL ABANDONMENT RECORD For Internal Use ONLY: !�
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 7a.Number of wells being abando'neld: 1
Well Contractor Name or well owner personally abandoningwell on his/her roe For multiple injection or non-svate�r supply wells ONLY with the same
( P y property)
consiruction/abandonment,you can submit one form.
A -4459
7b.Approximate volume of water re aining in well(s): (gal.)
NC Well Contractor Certification Number I
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS:ONLY:
I
Company Name 7c.Type of disinfectant used: i
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ij'known
7d.Amount of disinfectant used:!: �� — • i. �'R'�--�
3.Well use(check well use): ~!V 11 l=a=d"
Water Supply Well: 7e.Sealing materials used(check ll'that apply): [ w 2I123
❑A ricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑1IM10pi hips or Pellets
g 1?f ti,�y�.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout i' ❑ Dry Clay �y., -1.,;, Uri,(
j
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: IZI Bentonite Slurry ❑ Other(explain under 7g)
OMonit'oring ❑Recovery
Injection Well:
7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 65.0 GALLONS
❑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 2" WELL OVERDRILLED WITH 4 1/4" ID HSA AUGERS
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
ABANDONED VIA TREMIE PIPE
4.Date well(s)abandoned: 12/08/22
5a.Well location:
DUNN ERWIN LANDFILL
8•Certification:
Facility/Owner Name Facility ID#(if applicable)
449 DANIELS ROAD DUNN 28334 12/15/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
HARNETT By signing this form, I hereby certify that the well(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 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:
35° 21' S7.76" 780 38' 54.16" 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
wells ONLY with the same construction/abandonnrent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
M W-11 abandonment to the following:
6a.Well ID#•
Division of Water Quality,Information Processing Unit,
25.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: $'� (in.) abandonment to the following:
I �
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
t
10c.For Water Sunniv&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit f one copy of this form within 30 days of
completion of well abandonment,to,the county health department of the county
where abandoned. I
6f.Inner casing/tubing length(if known): (ft.)
I i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013