Wayne_Well Abandonment_20230227

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WELL ABANDONMENT RECORD . ti -Y=; ',
For,Internal Use ONLY: t `U �"
-- T.WellContractorInformation:- i WELL'ABANDONMENT DETAiLS'-I•
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0�t d1 L. �A7,'(T,jX . 7a.For Geoprobe/DPT et Closed-Loopi Geothermal Wells having the same�' '•
Wall ContractorNarne.far wellownerpersonallyabandoningw ell onluslher.property) well construction/depth,only1 GW-30'isneeded.Indicate.'10.1AL NUM BERof
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-. .-. abandon - - - -
- 3393 A4 --•
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.- NC Well Contractorrccnification Number• : • '. •• •- '7b..Approxima(e volume of Water remaining in wcll(s): (gal.),-
' CtS.CJ-de Jr, I I,/1,5•: FOR WATER SUPPLY WELLS ONLY:
.-.•... Company Name
' •' 7e:Type of disinfectant used:-• • • -
-- ' 2.Well Construction Permit tl: .: .: - .. _ .
--• ,'•'Listtillappl(cahleuellconsnucriarrpermirs(i.e.,t)lC-Counrp;Stare;,Varrhince,etc.)ifknoini --.• • - . - .. ...
7d.Amount of disinfectant used: '
3.Well use(check well use):
, Water Supply Well: - - ' '"- ' -' 7e.Sealingmaterialsused(check all;thrarapply): • •• •• --"•"-
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' .. ❑Agriculiuril _: : -• : -: ❑MunieipaWPublic - . ikSiCat Cement Grout. i n tletitnnite Chips or'Pel lets '
❑Gcothcinial(Heatiai/Cooling Supply):. OResidaritiar Water Supply{single) ❑"Said Cement(,rotit - 0 Dry Clay ."' "-' -'
❑IndustriaiICommcreial: - -'❑Residential Water Supply(shared) .❑,Concrete Grout: ' 0 Drill Cuttings . -
OTnigatioa• ::: , .❑'Specialty Grant::: 0 Gravel ... ..- .. ...
• • Non-Water Supply Well: -:• :- : - pOther
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entonite Slum• 0 (ei:plain under 7g):
. r ionitoring: ' ' ❑Recovery _ - - .. :.-
-Injection Well:. - - - 7f.For each material.selected.above,provide amount of materials used:
❑AquiferRecharge ❑GroundwaterReniediation -
❑Aqu . ❑ifer Storage and.Recovcry . . Salinity Bamer --
❑AggiferTest -: - = : •:❑StormwaterDrainage: : -- _
- ❑lperimcntal Teclinology ❑Subsidence Control .
7g.Provide a brief description of m
ithe abandonment procedure::'
,0Geotlierntal(Closed Loop) . •" . OTracer
-- ' ' ❑Geothermal(IieatimJCoo ling Return)-"' ❑Other(explain under 7g) "-' S /: -
^^.. : : . 1- c4-e per -Sc j"i :
d:Dale well(s)abandoned: d ' S a
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5aWell location:. .' . - ,.-:
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t% t nergV ' . .
FacilityiOwnerName •- -• - FaciliiyID»(ifapptidabte).• ,:8:Certilication::.: . - .:.. - - - ... .... .
7 (1I S cf i ' (c�( , otrdst ry ic z iz-,s- g
Physical-Address,City,and Zip . :. :•. ..- :- •Signature of Iiified-Wd1 Contractor b.Veil Owner:. •: Data': - ''
!Ain �� • • - '- By signdng.rhis foiur,=i herchy-ceitify:thatthe sreli(s)itus(us are)abandoned it -
'Cupiny - ' Parcel Ideutification No.(PIN)' "i' accordance with 15A NC/1C 02C,0100 or_2C.0200 Well Construction'Standards
and that a copy of this record has been pi•orided to the well owner .
a-b-Latitude and longitude in-degrees/minutes/seconds or decimal degrees: -
(ifnzp field.onelaUlnpgissu[reieriij '- _" '"""
2 9.Silc diagram or'nddttronnl well dcia�s:
- )G-.2.- y 5/ , _ N ;- .. g t ! 2.Qi - - `V .You may use the back of this page to:,provide additional well site details or Well./rye,.. ... -
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LJ"' :abandonment details.:You may also attach additional pages if necessary. •
' CONSTRUCrlON DETAILS-OF'VFLL(S)BEING-ABANDONED: SUBMITTAL INSTRUCTIONS'
' . - ,tract,nyilrnnarnretionrecard(.-)ifmaiahle.'Formultipleinjectionornen-water.slipplpurlls: . _ - - •
-- ONLY Kith the same canter?eriarvabandnnment,von can submit one farm. •-•--.' " - - --
:- - : •: •: tit, in 30 ofco p Well ,
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Oa For All �Vdls� Submit• 'c-form.vv�tli days -to /alien of�'
-.6n:Well II)# L i4oU 1.-' - abandonment tote following:
•- Division of Water Resources,Information Processing Unit,--
Gb.:Totalnelldepth: (ft.): 617- 27699-1617
1 Mail service Center,Raleigh NC
= - ' 10b.For-Infection Wells: In.addition to sending the form to:Me address in I0a. -
Ge.Borehole diameter': (in.) above,also submit one copy of this;Dann within 30 days of;completion of Well.--
.abandonment to the:following:
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": Gd.Water lcvel below ground surface: (ft.)
Division of Water Resources,Underground Injection Control.Program,
1636 Mail Sen•ice tooter,Raleigh;NC 27699-1636- --
be:Uuterca§ing.lcngth[ifknown): ' ' (fO 10c.For_Water Sunni Wel
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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
-6L'Inner casing/tubing length(if known): --Z' 7 5(fts) abandoned.__ ,__ •- _ .- - - _•-
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6g.Screen length(if known): (ft.): - - I - . •
.Fenn OW-ill North Carolina Department or Environmental Quality-DiuLddn Of Water itesources i - •-• •:•Revised 2-22 tat it-'
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