Vance_Well Abandonment_20230428

WELLARANDONIV1ENT RECORD For Internal Use ONLY:
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).NMI Contractor In ormation: WE_, ABANDONIIlENT )ETAlLS
®n d 6 7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Welt Canna r Ware Or well ounce tremens*abandontnn well on higher property) well consnuction/depth;only 1 GW-30'is needed. Indicate TOTAL NUMBER of
' a j I Pt . wells abandoned: r ... ,
NC Well Contractor Celligeidon Numblb.Approximate volume of water remaining is well(S): O (1a:)
�a�(]� f)OOerk We, f fan V- FOR WATER SUPPLY WfiLLS ONLY:
1,,
Company Neu e / • lc.Type of disinfectant used: r 1 %
2.WIJt;Ceus*ruetion Permit it: 1'1 L/' 1 r
List.altapplicable wet 1 constnwetlon permits a WC,County,Stare,Varlance,sic.)(fknown b
7d.Amount of disinfectant used: 3/: I
3 Well see{check well use):
WaterSupply Well: -.7e.Seahog materials used(checkfllt.8ust aptly):
°Agricultural CI VunicipallPublic 0 Neat Cement Grout . - sr Bentonite Chips or Pellets
N.
OGeathennal(Heating/Cooling Supply) logResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial °Residential Water Supply(shared) O Concrete Grout • 0 Drill Cuttings
°irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry . . 0 Other(explain under 7g)
CiMonitoring °Recovery .
Injection Wel: 7E For
I 1�ry(]each material selected above,provide amount of materials used:
ClAc`uifri nLe.harge aGtuundwatei r eMu diction 8 1. S 0#
°Aquif rStorageand Recovery °Salinity Barrier .JI
DAquifer;est DStorrin ,Drainage i eY1'1Dr t Tti 0 5 1 l') •
DExperimentat Technology °Subsidence Control 7g.Provide a brief description of the a oamemt�pihe14 t-
°Geothermal(Closed Loop) °Tracer / .I i �.�C,.
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DGeothemial(Heating/Cooiing�Reoim) DOther(explain tinder 7g) f a tit il Pill
APR2s '013
4.Date weit(s)abandoned: 1 ' 1 ''a�a ~ . 1?r�r L'tF
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• Ss..W .latatl0 - •
LI 10 wi 1-1-omeAs'..
Faclhy/OwuerName Facilhy30it(ifagylied:le) S.Certification:
al 35 S Fri h pr Vs.(i La� rC. 61 2 D- 2, :
Physical.Address.City.an82 v p Si of 'fled Well Co�tactor or Well Owner Date
� � � 1 1, er a n ��
N e c� s
`f an c.e, By signing this form.1 hereby cert*that the well(s)was(were)abandoned in
Coney • Pts:el rdsait6cftion No.(!IN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
andthat a copy ofth/s record has been providedto the weilowteer.
Sb.Latitude and lengitade in degrees/minuteslsecoadsor deelmal degreesr
.Owen field.ape latRang is siif3.:et) 9.Site diagram or additional well details:
N 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 WELLCS).BEING ABANDONED SURMITFAL INSTRUCTION4
Attach well corthripQlionmrord(e)ifavallable.F'armutaapi lnjsdtlonornon-watersuppllywells
ONLY with rile aaiire tv+ur ruction abandonment,you can submit ens form. 10a. For_All Wells: Submit this form within 30 days of completion of well
ba.Well ION: �^ abandonment to the following:
it Dhrialea of Water R�rrces.Information Processing Unit,
6b.Total well.depth: L1 0. (Ti.) 1617 Mall Service Center,Raleigh,NC 27699.1617
I 10b.For Infection Wept: in addition to sending the form to the address in 10a,
Sc.Borehole diameter: v (tn.) 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: a 5 (ft.) Division of v y e� , de uInjection
Nontrl Price ogram,
i69
v1 (A.. Imo.For Watxs snooty&inteetron Wells: in addition to sending the form to the
Sc.Outer casing ixltgtit tie unowat): r ' tt.) addneassfes)above,At suhmat ono cow of this form within 30 days of completion
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• of well abandonment to the county.health department of the county Where.
6f.Innercasingltublag length(if known): (R.) abandoned. .
6g.Screen length(if known) 0 (IL) . .
Penn OW-30 Noah Carolina Department of Environmental Quality-Division of Water Resources i • Revised 2-22.2016