Union_Well Abandonment_20230602 (2)

VMTL ABANDONMENT RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well fContractoYriInformation: WELL ABANDONMENT DETAILS
T,e111J\V-1% ob42 1\Ii�— 7a.Number of wells being abandoned: I
Well Contractor Name(or well owner personally abandoning well on his/her property) For nmlliple it jection or non-water supply wells ONLY with the same
constructionlabandonmenl,you can submit one form.
o
NC Well Contractor Certification Number 76.Approximate volume of`vatcr remaining in well(s): L O (gal.)
FOR WATER SUPPLY WELLS ONLY:Company Name 7c.Type of disinfectant used: V ,�'\
2.Well Construction Permit#: 7-�,
List all applicable well permits(i.e.County,Stale,irariance,b jection,etc)ii(known 7d.Amount of disinfectant used: \f1 S
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout jrBentonite Chips or Pellets
❑Geothermal eatin Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout 77, : 4V]. ,vrvaLy
41
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout - 'O bn16:'!uttings
❑Irri ation ❑ Specialty Grout J U N 6 2 2GZyravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected.aliov%;ipi3% ide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer {� F
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
cv oGs NY) A69 Pk IW
4.Datewell(s)abandoned: 4J1,� )pe��-dnlA-e,
5a.Well location:
Facility/Owner Name Facility IIN(ifapplicable) $•Certification.
• 2�"1 S y�c�ta� � �Monv-�e `^ � .���c.� _ S--�'2�2 3
Physical Addrgss,City,and Zip Signature of Certified Well Contractor or Well Owner Date
O 1Lk By signing this farm, I hereby certify that the ivell(s)'Pas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constniction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
t i O G� You may use the back of this page to provide additional well site details or well
����� N � 1 `2 \ir abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBIi4ITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple it jection or non-water supply
wells ONLY with the salve^^catslrtictiotr/abmtdonntent,your can submit rare form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• t V abandonment to the following: .
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
1 6d.Water level below ground surface: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
/� 10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) 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
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6f.Inner casing/tubing length(if known): t V (ft.) where abandoned.
6g.Screen length(if known): 1`1 (ft)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013