Wake_Well Abandonment_20230526 (5)

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 GW-30 is needed. Indicate TOTAL NUMBER of
2700 b 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 Chlorox pool shock
7e.Type of disinfectant used: P
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 6 OZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) R Concrete Grout ❑Drill Cuttings
❑lrri 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 ❑GroundwaterRemediation Concrete poured from bottom Poured in top of well
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage of Well to the Top
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal_(Heating/CoolingRetum)_ _0 Other_(explain under 7g) 6 oz of pool shock poured in well followed by filling
with 3000 PSI concrete from bottom to land surface
4.Date well(s)abandoned: 5-13-23
5a.Well location: MAY 2 7093
National Spiritual Assembly of the Bahais of the US n a
Facility/Owner Name Facility IDlt(ifapplicable) 8.Certific
410 Church Street, Morrisville NC 27560 5-23
Physical Address,City,and Zip Signature o erti ed 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 ivith 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 beIn provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35 49' 38.19" N -78 49' 46.08" 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
Allach well construction record(s)ifavailable.par 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-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 12 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 22 (ft.) 10c.For Water Suualy&Iniection 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
6f.Inner casing/tubing length(if known): N/A (fk) abandoned.
A'
6g.Screen length(if known): 'V/A (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016