Alexander_Well Abandonment_20230315

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Informs ion: WELL ABANDONMENT DETAILS
. tzfe 'J 7a.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,71y 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number F'= ,• ', ' `` 't . L) 7b.Approximate volume of water remaining in well(s): (gal.)
1,3 A MAR 1 b Z 023 FOR WATER SUPPLY WELLS ONLY: •
Company Name p '. i 11 a i 7c.Type of disinfectant used: n
1n c;,r.t::,icn . r:;
2.Well Construction Permit#: 1?j'i i317.3:7
List all applicable well construction permits(i.e.U/C.County.State,Variance,etc.)ifknown 07d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) tesidential Water Supply(single) 'Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
' ❑lrrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection-Well:_- __,_ v _ 7f._For_each_material selected above,provide amount of materials used: .__
❑Aquifer Recharge ❑Groundwater Remediation 5-''4 Ko -1 pi l /"
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer .
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) X£/Y1 '/� pG'Cu93 /3/�G — 1 GL /� /T
�t �- 5,4-ti-)7 /in /1C T 5_,
4.Date well(s)abandoned: 2' 1 -- .
Sa.Well locationkhakis �GG' "- < - 4T r�P
" r� -
Facility/Ownneerrf JName yicility ID#(if applicable) 8.Certification:
PhysicalAddress,City, dZip 23<vLio Si tore of Certified Well Contractor or ell Owner Date
Ae-w By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 let/long is sufficient) 9.Site diagram or additional well details:
3C°ST t 161W N V1"®17/1 9C"t ) 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can-submit-one-fora.
10a. For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: abandonment to the following:
7 ! Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12- (ft.) 1617 Mal Service Center,Raleigh,NC 27699-1617
•'.7 ;1 10b.For Infection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: Z (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: () • (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
7 , 10c.For Water Supply&Injection Wells: In addition to sendingform the to the
6e.Outer casing length(if known): �G (ft.) 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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