Burke_Well Abandonment_20230112

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
a
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple b jection or non-waterl supply wells ONLY with the same
construction/abandonment,you can submit one forn+.
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7b.Approximate volume of water remaining 5'0
in well(s): gal.)
NC Well Contractor Certification Number I,
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
C_y. E
Company Name .:* V
7c.Type of disinfectant used:
2.Well Construction Permit#: JAN 1 2, 2023
List all applicable well construction permits(i.e.County,Slate,Variance,etc)ifknown 7d.Amount of disinfectant used:
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3.Well use(check well use):
7e.Sealing materials used check all that a l rJl�� 1tJ�G
WateF$�pply Well: g ( PP Y)�
❑Agricultural ❑Municipal/Public ❑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) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9.0 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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder 7g)
4.Date well(s)abandoned: 12/21/22
5a.Well location:
KNOB SERVICE CENTER I.
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
1145 US - 70 CONNELLY SPRINGS 28612 01/09/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
BURKE By signing this form, 1 hereby certify that the rvell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35o 44' 21.23" 81 o 29' 54.97" 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
Altach well construction record(s)if available. For multiple injection or non-water supply
we/is 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#• MW-4R abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 56.0 (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
Gc.Borehole diameter: (in.) abandonment to the following:
25.0 (ft,) Division of Water Quality,Up
6d.Water level below ground surface: derground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
10c. For Water Supply&Iniectibin 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
6f.Inner casing/tubing length(if known): where abandoned.
(ft.)
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6g.Screen length(if known): (ft.) f
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 1113