Orange_Well Abandonment_20230626 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Russell James Turner 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
2448-A wells abandoned: f�
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): /� (gal.)
R.J. Turner Well and Pump, LLC. FOR WATER SUPPLY WELLS ONLY: C_h 1 G r:nC
Company Name
7c.Type of disinfectant used:C0.i(~i,-&— '=
2.Well Construction Permit#: w:Z '0 a'S 0
List all applicable well construction permits 6.e.UIC,Coun(v,State,variance,etc.)ifknowrt
7d.Amount of disinfectant used: 101"4 f7 Ce'S
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) iResidential Water Supply(single) i Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) O Concrete Grout ❑ Drill Cuttings
Oirri Lion '-"t" ❑Specialty Grout ❑Gravel
Non-Water Supply :r.��1., ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring very
Injection Well: I 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge im
mater Remediation ap� �' Q Ce-map k Gr IV.,O L&A (❑Aquifer Storage an#*ail&r.' . ity Barrier
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer ^^---- `�_
❑Geothermal(Hearin Goodin Return) ❑Other(explain under 7 ) �l� we I�CQS�n� �'�� •�P IOtt3 4Y'C�l9_rL� 4 feiC1E"�e.Je I
gaclCeA came^+
4.Date well(s)abandoned: A l DO 3 fCo rti
5a.Well location: (' rv-,@, * a cibu C M•xe -
�cRt.�hvrnrr<�u�,�r-;,�,1.
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
� 3
fir,. fXXebc,-e AL a1302, oI
Physical Address,City,and Zip Signature of ified Well Contractor or Well Owner Date
d e?an a l,- YU 6 61 i 0 1 By signing this form. 1 herebv certify that the well(s) was (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 record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if well field,one IaUbng is sufficient) 9.Site diagram or additional well details:
1 r O�e, r N -7(]� as 7_7 2 W You may use the back of this page to provide additional well site details or well
b J / 1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONb
Attach wrtl construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same consiretction/abandonment,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,
l
6b.Total well depth: 9 (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: (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: �15� (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(it known): U��� W '� (ft.) 10c.For Water SuvWv&Injection Wells: In addition to standing 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
6L Inner casing/tubing length(if known): DO abandoned.
6g.Screen length(if known): r% t-Ge-r (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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