Craven_Well Abandonment_20230406

WELL ABANDONMENT RECUR!) For Internal Use ONLY:
•
1.Well Contractor Information: WELL ABANDONMENT DETAILS
/1)/ )/1 41-t v I, eh// r I.. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally bandoning well on his/her property) well construction/depth, yJ GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: (D
3 S 7l, /a
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):2.3-0 I. (gal.)
/Qel/i L----,v,,,,vN,,,,,,f,,.../ FOR WATER SUPPLY WELLS ONLY:
Company Name
(,/ 7c.Type of disinfectant used:
2.Well Construction Permit#:NO r 7rac k:w W 10700535
List all applicable well construction permits(i.e. WC,County tate, Variance,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply:
❑Agricultural 0 Municipal/Public ❑ Neat Cement Grout entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout El Drill Cuttings
❑Irrigation ❑ Specialty Grout 0 Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring 0 Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:J
❑Aquifer Recharge 11BFiroundwatcr Rvtr�ediatiort 1 ./(L,A, s j e/Its f if //S � 2 Li// /1j
... PN t).tJi .� Cry t tr, JJ of F
❑Aquifer Storage and Recovery ❑Shtinityl3arder
❑Aquifer Test ❑Stormwate Draine"
❑Experimental Technology ❑SubsidU Control LO 23
i+, 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer •,c;�;)%: y y1�r L A /f
yn er(ex.._� 4--t/ -cc"cl4.1S:.vT''W ere A13ov a,, ,e ,:. ;7�`
❑Geothermal(Heating/Cooling Return) ❑Other(expl�i)i'iit�dt�� ,f 11
b.v/ov:/e elletS ,.,.radviceJhy 5/cLk)
4.Date well(s)abandoned:3--1' I Y ` 2-3
f PIA/y t" T71'f'✓ Ca-,[v(‘:f,.�} t M d..",t
5a.Well location: ,/ / / i ✓
ffw CCC CI,eM•gul Sales Nc0oo320/ $37
Facility/Owner Name Facility ID#(if applicable) S.Certification:
/I2.o b S/reet, orJjefaiv 2.85/9 ��2 3 -.26`13
Physical Address,City,and Zip Signature of Certified Well Contractor or Well O Date
C rA veN Z °p 0011
By signing this form, 1 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:
35.. 1 Zq so 6 N -7 7 0 Zy g/ 6 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/brm.
10a. For All Wells: Submit this form within 30 days of completion cf,••'I
6a.Well ID#: f
3 6 rv✓ e e �i V �Qr; 1l" abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: /S (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 -Z 5 (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: 3- 6 (ft.) Division of Water Resources,Underground Injection Control Program,
,/t�� 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): w4 (ft.) 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
6f.Inner casing/tubing length(if knuo n): /r/ (ft.) abandoned.
6g.Screen length(if known): J)///3 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016