Yancey_Well Abandonment_20230127

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I For Internal Use ONLY:
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1.Well Contractor Information: I
....eST- (}/1 WELL ABANDONMENT DETAILS
(9�4 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her Property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC We Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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FOR WATER SUPPLY WELIS ONLY:
Company Name 6-►2 A41 u iVI42 di Jl5Ptirl,,
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)if known O
7d.Amount of disinfectant used: /
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtmicipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) Iclitt<rential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustrialCommercial ❑Residential Water Supply(shared) Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation n j 7❑Aquifer Storage and Recovery ❑Salinity Battier yd
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❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pu 4&e FAO kl ;TO ta /T(� a q2
To •: t 4
4.Date well(s)abandoned: 0 g—ola
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5a.Well location:J
ic:ra i 'r 09aot^ Unit D maid
lKS'1 (VL3)41pODO i1ik1er30G Facility/Owner Name Facility ID#(if applicable) • 8.Certifl lion:
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Physical Addr ,City,and Zip G12
Sigaa a ifi Well Contractor or Well Owner Date
l k y By signing this form, 1 hereby certi that the well(s) was (were)abandoned in
Count ( Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: an that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
3S--° 91 t 4;7%4,(t1 I N Z.2- )9 r C)j,, ,l 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
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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fi) 1617 Mail Service Center,Raleigh,NC 27699-1617
(� 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) 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: 0- (IL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(If known): (IL) 1Oc.For Water Supply&Infection 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
6£Inner casing/tubing length(if known): (g,) abandoned.
6g.Screen length(If known): (D,)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016