Clay_Well Abandonment_20230602

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WELL ABANDONMENT RECORD For Internal Use ONLY: I
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1.Well Contractor Information: WELL ABANDONMENT DETAILS •
V EA reV V 1#a k4Aco S 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
wells abandoned:
1l251—C
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): cat) (gal)
Mk Ike r wet( "Dr l\.\1 a3 FOR WATER SUPPLY WELLS ONLY: ,,g 1
Company Name �1 7c.Type of disinfectant used: B2.5 9� Ski UM I� ehlor •
• 2.Well Construction Permit�: OZ2— I"2 O 1 f — 3
List all applicable well cortstntetion permits(i.e.WC,County;State,Variance.etc,)ifknown //��
7d.Amount of disinfectant used: I ( a II on,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑//Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
• ❑Geothermal(Heating/Cooling Supply) PlResidential Water Supply(single) ❑®Sand Cemenrirott ; ‘, -t-, :-— a:Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) CrF Concrete Groitt'`�'�-•'—'' ^° •�"• 4 -.€`hill Cuttings
• ❑Irrigation 0 Specialty Grout 1I r r' 2 2023 "Gravel
Non-Water Supply Well: ❑ Bentonite Slurp J L V d /
�d Other(explain under 7g)
❑i4onitoring ❑Recoveryfr,( 1.. ;.mil Prn,-,1A *,.3 1:
Injection Well: • If.For each niafenal sglgqttelaoy� provide amount of materials used: r—�❑Aquifer Recharge ❑Groundwater Remediation GM- Vf 1-
-Inn
_„ eOnc1e�"l MO I bS
❑Aquifer Storage and Recovery ❑Salinity Barrier `p o �pCy�y1� °'1
❑Aquifer.Test• ❑Stormwater Drainage NydrO91 C Ce rien4'—IG7a(bn
❑Experimental Technology 0 Subsidence Control '
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer p ' e-
❑Geother mil(Heating/Cooling Return) 0 Other(explain under 7g) .>\1/9.___ -U( pMen • B li_�1 I. � ?j Y below
. 4.Date well(s)abandoned: O3 iZ j2 r ( Q U Pd \ ' [n I t C
5a.Well location: lJ��► Q &
TayIOr ('-,ramchamp — d i r . C
• Facility7Owner Name Facility ID#(if applicable) 8. II
Z5G vJaiker C-bin4 RP, tAa viI lei zgg0� oy16,E f 23
Physical Address.City.and Zip S' nate o ertified Well Contractor or Well Owner Date
C(ay • 55'7OOgVI riy&2 By signing this fbrnr, 1 hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PLV) accordance with 1 4 NCJ4C 02C.0100 or 2C.0200 Well Construction Standards
• crud that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
Ji7
2rO 02l 02..
20 " :-- o.415
CWl� I,G.t( `fit 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)ifavailable. For Multiple injection or non-water supply wells .
ONLY with the same construction'abandontnent,you can submit one form.
10a. For All'Wells: Submit this form within 30 days of completion of well
6a.Well ID?i: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: IZO (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
• r lob. For Inlectdti 13 eBs: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 (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: 20 (ft) Division of Water Resources,'Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 30 (ft.) 10c.For Water Supply&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
• 6f.Inner casing/tubing length(if known): NJ I A (ft) abandoned.
6g.Screen length(if known): NIA . (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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