Caswell_Well Abandonment_20230515

JELL ABANDONMENT RECORD
For Iniemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David Hardy 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
2906—A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): J (gal.)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits('.e UIC,Cotauy,State variance,etc.)iflmown
7d.Amount of disinfectant used: �fJ f/ M r—
3.Well use(check well use): r8'
Water Supply Well: 7e.Sealing materials used(check all that apply): MAY
v
❑AgdcuItural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips orPellets G 2l'n
23
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) CWConcrete Grout ❑Drill Cuttings '3!
❑hri ation ❑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 .mil 1/
❑Aquifer Storage and Recovery ❑Salinity Barrier b•
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) r 12 L
4.Date well(s)abandoned:
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) S.Ce ation:
y'Phcal Address,City, d Zip' Sigrmture of Certified well o(y� c r or Owner Date
County By signing this form,I herby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b:Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/Iong is sufficient) 9.Site diagram or additional well details:
N �t� �9�` 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)ifavarlable.For multiple bliectionornon-watersupplvwells
ONLY with the same construction/abandomnent,you can submit one form.
10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 7 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection Wells: In addition to sending the form to the address in I Oa
6c.Borehole diameter: (�.) 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: Ke_(fo Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
6e.Outer casing length(if known): (ft-) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
addresses)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 known): (ft.) abandoned.
6g.Screen length(if known): (ft,)
i
FormGW-30 North Carolina Department
P Quality-Divisianof WaterResaurces Revised2-22-2016