Union_Well Abandonment_20230602

♦V LL ABANDONMENT RECORD. For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor 14RTmation: WELL ABANDONMENT DETAILS
�lil 3'rl S V10 �'Y�: 7a.Number of wells being abandoned;
Well Contractor Name(or well owner personally abandoning well on hisiberproperty) For multiple injection or »on-water, supply wells ONLY ivith the same
constructloniabmtdonment,you can submit aneform
�33a-ci ''JJ
NC Well Contractor Certification Number 76.Approximate volume ofwater remaining in well(s): (gal.)
C, 1 l lu J w FOR WATER SUPPLY WELLS ONLY:,
Company Name 7e.Type ofdisinfectant used:
2.Well Construction Permit
List all applicable well permits(l.a.County,State,Pariance,Injection,eta)ii&nown 7d.Amount of disinfectant used- d I-
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) dil Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑indtrstriaUCommercial ❑Residential Water Supply(shared) (].Eoncrcte Grout :n s ,:
y i f'quttings
0
❑Irri ation ❑Specialty Grout ❑Y'itaiiel
Non-Water SupplyWell: ❑Bentonite Slurry J L y d 2 023Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 711 For each material selecte4a oge„proy(de nt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation `Z- /2
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
OF-xperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
x�, 2� /?o�-n 3
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) � / I j
4.Date•well(s)abandoned: /
5a.Well location:
Facility/Owner Name Facility ID9(ifapplicable) $•Certification:
Z''(/Z t ._ Z3
Physical Address,City,and Zip C, Signature ofCertificd We auactor or Well Owner Date
V)r u r+ © /' 2 Q By signing this form, 1 hereby cerh;fy that the well(s)ivas(were)abandoned in
County parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this retard has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwell field,one laWong is sufficient) 9.Site diagram or additional well details:
1), j p N ��•
�1 O W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consirrclion records)ifavailable. For multiple injection or non-water supply
wells ONLY with the same constructimdabandonment,you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
6a.Well EN: VV abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (fk) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6�Borehole diameter:. (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
e
6d.Water level below ground surface: ({L) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c. For Water Supply&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
6f.Inner casing(tubing length(if known): ({L) where abandoned.
6g.Screen length(if known): ow
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013