Yancey_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.` /�
Well`6 Contractor Information: WELL ABANDONMENT'DETALS
4 moo ro o A. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
(\ 9 I ` A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gat.)
A C
. , FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifI•nown ( ,�
7d.Amount of disinfectant used: L�-
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Ag;cultural blic ❑Neat Cement Grout ❑Bentonite Chips or Pellets r
❑Geothermal(l leating(Cooling Supply) ❑MunicWater Supply(single) ❑ Sand Cement Grout ❑Dry Clay c� -^
❑lndustrial/Commercial ❑Residential Water Supply(shared) ncrete Grout ❑Drill Cutti�luilR 2 I 2023
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 'r;_ •.8 ' l( .g ur4;:
❑Bentonite Slurry ❑Other e I
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 l�l'�I 1 '�)n)nip )0.
4.Date well(s)abandoned: �� J
5a.Well location:
6Z9 Nihu�k— PeimmcW,
Facility/Owner Name Facility ID#(if api qIicable) 8.Cc
Physical Address,City,and Zip Signa ed Well Contractor or Well Owner Date
t 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 lat/long is sufficient) 9.Site diagram or additional well details:
Q11 lJ` /r�J N Do
ar7(, it � 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 conslructionlabandonment,you can submit ore form. 10a- For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
t Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
v 6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (M) 10c.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 where
6E Inner casing/tubing length(if known): (fL) abandoned.
6g.Screen length(if known): (M)
Form GW-30 North Carolina Department of Fnvuonmental Quality-Division of Water Resources Revised 2-22-2016