Nash_Well Abandonment_20230113

WELL ABANDONMENT RECORD For Internal Use ONLY:
L Well Contractor Information: WELL ABANDONMENT DETAILS
Michael Young 7a.For Gwprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hulber property) well constmetion/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2370-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): 0 (gaL)
Fishburne Drilling Inc. FOR WATER SUPPLY WELLS ONLY:
Cornpany Name
NCD045646924 7a Type Of disinfectant used:
2.Well Construction Permit ft: -a J_r►
List all applicable well cnnrouction permit/(Le.UIC,County,State.Variance,etc.)If nine, i.
7d.Amount of disinfectant used: JQ IV 1 a•
3.Well use(check well use): .�
Water Supply Well: lc.Seating materials used(check all that apply):
❑Agricultural ElMunicipal/Public ■Neat Cement Grout ❑ Btstomite Chips or Pellets
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) O Send Cement Grout ❑Dry Clay
❑InduslriattCommemial OResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
01ringation ❑Specialty Grout ❑Gravel
NowWater Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ORecovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remedimion 5.5 gallons
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
❑Experimental Technology OSubsidence Control
711.Pruride a brief description of the abandonment procedure:
oGeothetmal(Closed Loop) OTmcer Tremie grouted from the bottom of the well to the surface
❑Geothermal(Hcatin Coo' Return) OOther(ex lain under 7 )
4.Date well(s)abandoned: 11-03-2022
5a.Well location:
Kaba IIGo Corp. �yL//J�
Facility/Owner Naas Fcility IDk(if applicable) 8.Cey��' I
400 Jeffreys Rd., Rocky Mount, NC 12-05-2022
Physical Address,City,and Zip Signature of Certified Well contractor or well ■r Dole
Nash
By signing this form, (hereby certify t the we//(s) wns (were)abandoned in
County Parcel Identification No.(PIN) acrordonce with 1 SA NCAC 02C.0700 ar 1C.0100 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrces/minutes/secopde or decimal degrees:
(if well field,one belong is sufficient) 9.Site diagram or additional well details:
35.988408 N -77.7,65560 W 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
At hwellmw"ctionrmrd(s)ifavailable FormWtipleinjection or o n-warermpply wells
ONLY with the same mnrtructia�fwndonmenq you can submit one(arm.
,If, file. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDp: Y Y-^1 abandonment to the following:
4 Division of Water Resources,Information Processing Unit,
6b.Tonal well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lidectioo Well ; In addition to sending the form to the address in 10a
6c.Borehole diameler- 4 (i„) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (B-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
be.Outer casing length(if known): 20 00 10c.For Water Supply&Injection Wells: In addition to sending the form to 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 where
6f.Inner casing/tubing length.(if known): 20 (R) abandoned.
c
6g.Screen length(if known): I O 00
For a GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016