Vance_Well Abandonment_20230626

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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 I GW-30 is needed. Indicate TOTAL NUMBER of
U wells abandoned:
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
L,1[J e- L FOR WATER SUPPLY WELLS ONLY:
Company Name y 7
�f tltl 7c.Type of disinfectant used:_ ,! , �/ /
2.Well Construction Permit#: 3 0 lEtJ�
List all applicable well construction permits(i.e.UIC.County.State.Variance,etc.)if known 110
/_7d.Amount of disinfectant used:_
3.Well use(check well use):
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Water Supply Well: 7e. hng materials used(check all that appI • t /�..L
❑Agricultural ❑Municipal/Public eat Cement Grout ROBentonite Chips or Pellets❑Geothermal(Heating/Cooling Supply) 4RI sidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay J L N 1) i 2023
❑Industrial/Commercial El Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel InfG�'rY:a/�1 't`'` U
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g) L\,tiJfDi3
❑Monitoring ❑Recovery
Injection WeU: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation IISVI/_s „_ _f J y rJ�I�
❑Aquifer Storage and Recovery ❑Salinity Barrier 7 !r// /❑Aquifer Test ❑Storrnwater Drainage j� D/t
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer j
Wt �1.❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) Ll'1�d. -
4.Date well(s)abandoned: Ito 2-3 )
gc1.r ,Pl��/�L✓t C u D O 6'A
sa.W7 location:
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Facility/Owner Name Facility ID#(if applicable) &Certification: /OP—se'
Physical ddress,City,and Zip 2_7 53 igm ed Well Contractor or Well Owner Date
1�YtC t By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
� a �[�� W You may use the back of this page to provide additional well site details or well
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�l�► 7 O J 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 constructionlabandonment,you can submit one form. 10a. For All Wells: Submit this forth within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:_ 2 o (fL) 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: above, also submit one copy of this form within 30 days of completion of well
q abandonment to the following:
6d.Water level below ground surface: r7 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 42 (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 where
6f.Inner casing/tubing length(if known): ' (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016