Richmond_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1. ell Contractor Information: WELL ABANDONMENT DETAILS
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� ) �Y-) r L 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
3 Frig/_7—G construction-abandonment,you can submit one form.
NC Well Contractor Cc fieation Number 7b.Approximate volume of water remaining in well(s): (gal.)
eC 1 t(„U FOR WATER SUPPLY WELLS ONLY::
Company Name 7c.Type of disinfectant used: /
2.Well Construction Permit#:3
List all applicable well permits(i.e.County,Stale,1'ariance,Injection,etc.)if!mown 7d.Amount of disinfectant used: OL
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply Una
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout Wtentonite Chips orA11ef11i30ig
❑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: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5 OGue.S
❑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 O ��G� ��G•
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
4.Date well(s)abandoned: QA O
5a.Well location:
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Facility/Owner Name I Facility ID#(ifapplicable) 8•Certification:
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Ph ical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
r� By signing this form, I hereby certify that the ivell(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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
9 L/ glq t�6 N �17, f�(/5 0 5 W You may use the back of this page to provide additional well site details or well
7 7 e abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(.t)if available. For multiple injection or inn-}racer supply
wells ON1.Y with the same construction abandonment,you can submit one form. 1 Oa. 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: /00 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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
6c.Borehole diameter: (in.) abandonment to the following:
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6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
tie.Outer casing length(if known): (ft.) the
For Water Supply& Iniection 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
6f.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 Resources Revised August 2013