Stanly_Well Abandonment_20230807 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information:: WELL ABANDONMENT DETAILS
"', el ( J�/� lit.C'_ +-» 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 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): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: �� r
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
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 �:k
❑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 ravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
/Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 6'p U
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test 1OStormwaterDrainage
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer / ` O
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) v���� �� La,r/J"� ��
C_ - i'�i'1, dC',k e­y ICGy'�'i/
4.Date well(s)abandoned: e6 ` D 21 L
5a.Well location:
Facility/Owner/Name / Facility IUD##(if applicable)) S.Certification:
Zli/t Xf 9, //
Physical firessss,City,and Zip �Y Z'p o$6 Signature of Certified Well Contractor or Well Owner Date
n` By signing this form, I hereby certify that the well(s) was(were)abandoned in
County J 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 lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
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abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstructionrecord(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same consuuctionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: & ' 91 y'l`" 0C2-7— abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.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: �. (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): ( ) 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): /!1 (ft.) abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016