Wilkes_Well Abandonment_20230419

WELL ABANDONMENT KECUKt11 For Internal Use ONLY
1.`W'ell Contractor Information:/ I- ' ABANDONMENT DETAILS
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�J C1EfM g S 1�hLl /V'e/r�VXQ j`oC.7 /T 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 tieeded. Indicate TOTAL NUMBER of
well isabandoned:..—
NC/Well Contractor Certification NNuumber.,[� 7b.Approximate volume of water remaining in we9(s): ! (gal.)
C' FOR WATER SUPPLY WELLS ONLY:
Company Name N
, I 7c.Type of disinfectant used: _ �f
2-Well Construction Permitlt: �J
l.dat all applicable well cnnsrrncdon permits(i.e.II/•.r•anntr Slate.)•arimrce.erc•.1 ilArro+nr 2 O-�
7d.Amount of-disinfectant used:
. V
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) iidResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) B2oncreteGrout ❑Drill Cuttings
❑Irrigation N ❑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 Ayt?
❑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
❑Geothermal(Heating/Cooling Return) ❑Chher(explain under 7g)
4.Date well(s)abandoned:
Sa.Well location: APR 1
ifl?�_"i�•T::;.,"i v_'=;r:1 lit,;?
Facility/Owner Nan - Facility-ID#tifapplicable)r 8.Certification: , vt,`r`i t'•..�1
folve—
Physi%T Address,t,tty ana i t +�nazur o ertified allell caner Dale
W/�lL'eS CSD h�o 1) gy signing dos lbrm, I hereby certo that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) uccordunce willr 1.5-4 XC'AC O2C'.0100 or 2C.0200 Nell C'onsrruclion Standards
and Mal a cony r f'/his record huv-been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(it'well field.one[at/Ion,.is�cient) r 9.Site diagram br additional well details:
O 9 �f N �.3 W You may use the back of this page to-provide additional well site details or well
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C✓ 1-2&0 abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
.9tmch+rellcansrnrclinnr¢ev�rtl(.cl ifmadahlr:l•irrmnhipleinjeclionarnon-u•arersupplyirells
ONLY+rich the same constnrction ahantloumenG rnu cell,suhmit ofin ne ial.
7�� j IOa. For All Wells: Submit this fcZ\m within 30 days of completion of well
6a.Well ID#: 7 ��f/ abandonment to the following: t
Division of Water Resources.Information Processing Unit,
6b.Total well depth: r(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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� 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter CO (in.) above,also submit one copy of this form within 39 days of completion of well
abandonment to the following:
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): Q (ft) 10c.For Water Suuuly&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
nn of well abandonment to the county health department of the county where
6E inner casing/tubing length(if known): V (ft) abandoned.
6g.Screen.length(if known): (ft
Fovn OW-30 North C olina Dcpartmcm ut•L"nstronmental Quality-Division of Water Resuurces Revised 2-2-2016
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