Union_Well Abandonment_20230602 (3)

WELL ABANDONMENT RECORD. For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS �J
Y t 5 ?I C' 7a.Number of wells being abando I ed:
Well Contractor Name(or well ow4x personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY ,vith the same
constructionlabandomnent,you can submit afire form.
Lf'33 X -
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name _ 7c.Type of disinfectant used: t l
2.Well Construction Permit#:
List all applicable well permits(i.e.County;State,Variance,Injection,etG)iflmmvn 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) i]Residential Water Supply(single) ❑Sand Cem Ott. routs`-�o,:_'?:,a q' a 7=0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) �ete t.ri-out�'�"' '•�'min Drill Cuttings
❑Irri ation ❑Specialty Grou9 U N J 2023 ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery 4n,c;1; `:_'^� �;:�:=-3+,a= I ln�
Injection Well: 7f.For each material elected allgve,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery ❑Salinity Barrier '
❑Aquifer Test ❑Stormwater Drainage
❑F-xperimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) � � �'" } via d►T�i v P C u
./ _ �-� cgs-z, ¢-- � l��.0 �, 1 (�o�,�.✓��
4.Date wells)abandoned: !i Z/ 23
5a.Well location:
Facility/Owner Name Facility ID#(ifapp)icable) 8-Certification:
41CA w u t ► bY)Y 6C
Physical Address,City,and tip Signature ofCcMcd W ctor or Well Owner Date
uyli o,n o9—3S 1 -ot� By signing this farm. I hereby certify that the ivell(s)was(were)abandoned,in
County Parcel Identification Igo.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Slandwds
and that a copy of this record has been provided to the well oumer.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lar/long is sufficient) 9.Site.diagram or additional well details:
You may use the back of this page to provide additional well site details or well
' 7 a c��� N / �'tr abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUIlMrl TAL INSTRUCTIONS
Attach well construction record(s)!#available. For multiple iu jection or non-water supply
irelis ONLY with the same coustruction4abandonmen;you can submit one form. 10a. For All'Wells: Submit this form within 30 days of completion of well
6a.Well IM: �j abandonment to the following:
�l 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
6c.Borehole diameter:. e/ {in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
P
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): 11U (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
6f.Inner casing/tubing length(if known): ! (ft) where abandoned.
6g.Screen length(if known): (ft) _
II
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Rcsources Revised August 2013