Wilkes_Well Abandonment_20230419 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: ,*fI WELL ABANDONMENT DETAILS
Jiyyt e S /�/� C nft2 /Y @L��tv�Ll yL 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contactor Name(or well owner personally.abandoningwell on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Welt contactor Certification NumNumber7b.Approximate volume of water remaining in well(s): (gal.)
/1I a l tf/y apt J?lI�tAer5 FOR WATER SUPPLY WELLS ONLY:
Company Name 7�Type of disinfectant used: � T 7�
2.Well Construction Permit#:
List all applicable well construction permits(1.e.UIC,County,State,Variance,eta)ifbmwn - d
7d.Amount of disinfectant used:
3.Well use(check well use): _
Water Supply Well: 7e.Sealing materials used(check all that apply):
OAgriculturd ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heatmg/Coohng Supply) �idential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commerdal ❑Residential Water Supply(shared), R<oncrete Grout ❑Drill Cuttings
01ni 'on ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: `7L For each material selected above,provide amountof materials used:
❑Aquifer Recharge ❑Groundwater Remediation ST r-144
❑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) ❑TraceFr _. - 5
❑Geothermal eating/Cooling Retum) OOttieij plain under 7g) i
n 4T
23
4.Date well(s)abandoned: .Z—o�U�:3 - 1
Sa.Well location: 1O ,.
9)crabs
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
�� '/k esdofa l rJl .
Physical Wilke-5
City, d Zip ignaww of Certified Contactor or Well Owner Date
Ltd Il ke-5 > d�' � By signing this form I hereby certify that the well(s) was(were) abandoned in
cc ty. 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/minutgs/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) - r! 9.Site diagram-oradditional well details:
�j �� 49 1.3 1—c W You may use the back.pf this page to-provide additional well site details or well
•7 � N l�S� •1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well constructionrecord(s)ifavailable.For`multiple injection ornon-watersupply wells
ONLYwith the same construetionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDN: U 1!oZoZGtJ abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: .� Z (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: (ft.) Division of W ater Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): 4 (ft) 10c.For Water Suunly&Inh ecuon wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30#ays of completion
of well abandonment to the county health department oft the county where
6L Inner casing/tubing length(if known): (ft,) abandoned
6g.Screen length(if known): A)

LOAM.
,I
I
i