New Hanover_Well Abandonment_20230626

WELL ABANDONMENT RECORD For Internal Use ONLY: .
1.Well Contractor Information: WELL ABANDONMENT DETAILS
G.4 YZ.. 3-C)Ill S 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contract&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:
' NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): /de (gaL)
A Nit, A 4J e l f OR, )( ,I1/40 O FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: /o a L S 1:lr
2.Well Construction Permit#:
List all applicable well construction permits(Le.UIC,County,State,Variance,eta)if known
7d.Amount of disinfectant used: a 1-.00
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout %Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
0 Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
hrrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry
_ ❑Monitoring ❑Recovery 0 Other(eaplain under 7g)
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery 0 Salinity Barrier / 4 'J°s'
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Traced
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)_ t..�. -.t Ae�c��e/_0 0 • i . �y tJC.LI SCr , J-'a
// C -1�,,,at.:`'�� p bat. S ]cA O�.ire4 Loft** /k` Nba,v-I
d.Date wells)abandoned: l�` Z)`�� `
Jtill-, 23 cl4, �r
5a.Well location: Ln°x
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
3'l.. w/,L%<i,L /4//S ) a. ,L• 14 , ,cJ'G L(og 'OI-013
Physical Address,,/
City,and Zip Signature of 'ied Wet actor ell Owner Date
A.)o�.l Nn Deer By signing this fo n,I ereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 5A NCAC 02C.0100 or 2C.0200 Well Construction 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
3 . b 5'/ /? N 77 d ScJ 13? lr W 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable For multiple injection or non-water supply wells
ONLY with the same corstruction/abandonmen4 you can submit one form. 10a. For All Wells: Submit this form 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: liS (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: L (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: l D (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 15' (g.) 10c.For Water Supply&Infection 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
6E Inner casmg/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): a O f (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016