Lee_Well Abandonment_

WELL ABANDONMENT RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells I'
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 injection or no
I supply ivells ONLY with the saute
A -4459
construction/abandonment,you can submi I one I form.
5.75
7b.Approximate volume of water remaining
aining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
'IN r'
2.Well Construction Permit#: 20'
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown 7d.Amount of disinfectant used:
In`:,- -
-'4:•::,1 .fir
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check al1 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: El Bentonite Slurry ❑Other(explain under 7g)
[?]Monitoring ❑Recovery
Injection Well: 7f.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 under 7g)
4.Date well(s)abandoned: 12/07/22
Sa.Well location: - - -
CIRCLE K- 2720355
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
429 EAST WEATHERSPOON STREET SANFORD 27330 � � 01/09/23
Physical Address,City,and Zip Signature ofCertified Well Contractor or Well Owner Date
LEE By signing this form, 1 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 fat/long is sufficient) 9.Site diagram or additional well details:
35° 29' 17.32" 790 10' 05.17" 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-10 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
55.0 1617 Mail Service C;�enter,Raleigh,NC 27699-1617
(ft.)
lob. For Infection 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
6e.Borehole diameter: 2.0 (in.) abandonment to the following:
20.0 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 Supply&Infection 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
� -
611 Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water�uaiity Revised March 2013