Rockingham_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
M Q /'V tom. �!✓�� 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Con for Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 G W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
N Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gaL)
11 1♦AA n A Q I��V1 �Q /1 FOR WATER SUPPLY WELLS ONLY:
Company Name
e
7c.Type of disinfectant used:
2.Well Construction Permit#: MAR 2 i 202
List all applicable well construction permits(Le.UIC.County,State, Variance,etc.)ifknowvt
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Vesidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commcrcial ❑Residential Water Supply(shared) Voncrete Grout ❑Drill Cuttings
❑Irri ation ❑SpccialtyGrout ❑ Gravcl
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.Fnr nch material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �l a
❑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 LA
❑Geothermal ea' Coolin Return) ❑Other(explain under 7 TO ` I0, 1('_ t nA i pe
4.Date well(s)abandoned:
5a.Well location:
�Iru Gc
Facility/Owncr Name Facility ID#(if applicablc) g.Certification:
Physical Address,City,and Zip Sig6ture of rtified Well Contractor or Well Owner Date
(n►`a_m By signing this form,I hereby certify that the wells)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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)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 form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDk#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in IOa
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 4/0 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
x
fie.Outer casing length(if known): (fw) 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): (fL) abandoned'
6g.Screen length(if known): (fL)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016