Burke_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 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-ware' supply ivells ONLY ivith the same
construction/abandonment,you can submit o ie form.
A -4459 }
7b.Approximate volume of water remaining in well(s): 1'0 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: r -
Company Name
7c.Type of disinfectant used: ,•
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2.Well Construction Permit#: 1 `LI�" 3
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknoivn 7d.Amount of disinfectant used:
men._,.._ •..:•71-t:it
3.Well use(check well use):
Water Supply Well: 7e.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 Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 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 under 7g)
d.Date well(s)abandoned: 12/21/22
- 5a.Well location: -- - -- — — } - -
KNOB SERVICE CENTER
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 well(s)ivas(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 la/long is sufficient) 9.Site diagram or additional well details:
350 44' 21.23" 810 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
Attach well construction record(s)if available. For multiple injection or non-water supply
wells 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-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
18.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
I;
IOb.For Infection Wells: In addition to sending the form to the address in IOa
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:
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11.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water SnDDIV&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit J;orie copy of this form within 30 days of
completion of well abandonment to Ith6 county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known): (ft.) l
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013