Orange_Well Abandonment_20230626 (3)

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:--
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): _(g�•)
R.J. Turner Well and Pump, LLC. FOR WATER SUPPLY WELLS ONLY:
Company Name �t 7c.Type of disinfectant used: c `� wry O C,)IY 1 G V, �,C
2.Well Construction Permit#: 0 a 1 q
List all applicable µell construction permits(i.e.UIC,County,State,Variance,etc.)ii known
7d.Amount of disinfectant ua+ed: -
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) *Residential Water Supply(single) ®Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:— tf}-•^ ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring t �F k1b ee6ery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑A uifer Recharge Iu 2��Groundwatcr Remediation C� r/ 1 / 6.
9 g Jl1y c/�t!�('S S�,�C�c Inn-f- rJ rci u
❑Aquifer Storage and Recovery ]St+�inity
❑Aquifer Test ltl(;,:T,:rr Y ' ,y i7Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7 Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer k
f `t
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) k-���`t-� �'�-t C�� �� �1-
tJCY['.��C'tL ('MLs1.�" rc._CA/-, V 0
4.Date wells abandoned:(^V"� 2 C .l
5a.Well location:
ion: n
f3UL K ,, _T" t S t,Cs( f'IA\
Facility/Owner Name Facility ID#(ifapplicable) 8XSiiga�t=
Certification:
mA tz73t� "7
c,bc.rr.L ti ��_� � -_ rnL\I, 23
Physical Address,City,and Zip f Ce Well Contractor or Well Owner Date
rxA C_ C 0 LA nS� L—A'�5 3 LIO UP 0 1 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.
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:
01 Ll C' I N - 7 9 /) '1"�c�c6G(_ W You may use the back of this page to provide additional well site details or well
3 abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTION
Attach Kell construction record(s)iifavailable. For multiple injection or non-watersupply Nrlls
ONLY Hith the same constructionlabandonment,you can submit one fcnar 10a. For All Wells• Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
!� Division of Water R,=sources,Information Processing Unit,
6b.Total well depth: 1 _(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
C 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter (lo.) 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: T�1/ , (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): r1`j ��� �'� (ft.) S lOc.For Water Supply&injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
CC4of well abandonment to the county health department of the county where
)
6f.Inner casing/tubing length(if known):R t) nee( S ^ department abandoned.
6g.Screen length(if known): n L� ��C CL e,N (ft.)
Form C W-30 North Carolina Department of Environmental Quality-Division of Water Resotncs Revised 2-22-2016

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