Union_Well Abandonment_20230724 (3)

WELL ABANDONMENT g RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Co tractor Information: WELL ABANDONMENT DETAILS
� 11
f)5 1 G 7a.Number of wells being abandon ed:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water, supply wells ONLY with the same
constructionlabandonmeni,you can submit one form. 0(,,
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ` (gal.)
)U -ei U. 'S W W of LW r` FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: 1�I
2.Well Construction Permit#:
List all applicable rvellpermits(i.e.County,Slate,Variance,Injection,etc)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ntte Chips or-Pellets
❑Geothermal(Heating/Cooling Supply) DBegitierttial 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: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation -3 s
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer cXCtt 3/ y�gJf
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: �13 /3„PhH yl �
5a.Well location: R E d L
R<'' ) W o 3o n Facility/Owner Name Facility ID#(if applicable) 8•Certification: J U L 2 4 2023
5c�s 01 b C10,L"e Mo>1rcyF- ,tier 1•irj;jC RrC,r b 0-9 J23
PhysicalQ Address,City,and Zip 212 V i' Signature of Ce fied ctor or Well Ow X��' Date
`th J C^�*1 Q 13 �p(p(7 A By signing this form,I hereby certify that file ivell(q)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction Standards
and that a copy of this record has beery provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
3 •©\ N IDZO W—)0< C� J� 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
Allach well construction record(s)if available. 1•or multiple it jection or notr-water supply
wells ONI.Y rrillr lte.vame con tnnctioniabmrda»ment,you can stibnrit onefornr. 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: C)3 (ft,) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: Li (in.) abandonment to the following:
Gd.Water level below ground surface /� (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service CcInter,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): 'N� (ft.) the address(es) above, also submit one copy of this form within 30 days of
p completion of well abandonment to the county health department of the county
6E Inner casing/tubing length(if known): where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013