Wake_Well Abandonment_20230526 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL'ABANDONMENT DETAILS
Thomas Will 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 GWL30 is needed. Indicate TOTAL NUMBER of
2700b wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name pool ool shock
7c.Type of disinfectant used:
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 6 Oz
7d.Amount of disinfectant used:
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) CResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete poured from bottom Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage of Well to the Top
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geotheanal(Closed Loop) ❑Tracer
6 oz of pool shock poured in well followed by filling
❑Geothermal(Heating/Cooling Return)___pother(explain under_7g) ___.
with 3000 PSI concrete from bottom to land surface
4.Date well(s)abandoned: 5-13-23
5a.Well location: "� .. a
National Spiritual Assembly of the Bahais of the US n a MAY 2
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Facility/Owner Name Facility ID#(if applicable) 8.Certifrcatio
410 Church-Street, Morrisville NC 27560 1n""'t"�' '� ,r,�' 'Jt_�Uri
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wake 0755066002
By signing this form, I hereby 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
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(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
35 49' 36.02" N -78 49' 47.86" 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 WELLS)BEING ABANDONED - SUBMITTAL INSTRUCTIONS
Attach well consiruction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (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: 4 (ft) Division of Water Resources,Uuderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 22 (ft.) 10c.For Water Sunuly&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
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 'A'V/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
I
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016