Union_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well C ntractor Information: WELL ABANDONMENT DETAILS 1
� ) S PIoe—il7a.Number of wells being abandoned: J
Well Contractor Name(or well ow r ersonally abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY with the same
3.. )�)C construction abandonment,you can submit one form_ '\
NC Well Contractor Certification Number II l 7b.Approximate volume of water remaining in well(s):
ID U �(ALL) Uy& V V D( I l 1-\ FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: yJ'
List all applicable well permus(i.e.County,State, variance,Injection,etc,)i#-known
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) ❑Residential Water Supply(single) ❑�ement Grout ay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑ Drill Cuttings
❑Irri ation ` _ ❑ Specialty Grout ❑Gravel
Non-Water Supply Well:' ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring r overy
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquiter Recharge L1Gn#undwater Remediation
In;
❑Aquifer Storage and Recovery_,%',;_;, :;.:,dpSalinity Barrier
❑Aquifer Test ❑Stormwater Drainages
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) y
4,Date well(s)abandoned:
5a.Well location:
v
Facility/Owner i ame Facility ID#(ifapplicable) 8•Certification:
to c) 0 i 1a.. AR Slav,l)0-0 -3 (,/�3
Physical Address,City,and Zip mo 7 f cc Kc- 7,2(03 Signature ofCcnij&Mcll Contractor or Well Owner Date
By signing this form, I hereby certify that the ivell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC.4C 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 latflong is sufficient) 9.Site diagram or additional well details:
(� $'3 n 63 N _pQ - 1 I-� �b You may use the back of this page to provide additional well site details or well
7 W, 6 `t b abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s))available. For multiple injection or non-water supply
wefts ONLY with the same constructionrubandonment,you cart submit one form. 109. 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: (0 0 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
�tQ above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
r
j O 6d.Water level below ground surface: ) Division of Water Resources,Underground Injection Control Program,
(ft. 1636 Mail Service Center,Raleigh,NC 27699-1636
l0c. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known):_ (ft.) 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