New Hanover_Well Abandonment_20230818

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gi9-f'V O A. eJ 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): [/ (goL)
FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e. UIC,County,State,Irariance,eta)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 KBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
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
❑Aquifer Storage and Recovery ❑Salinity Barrier / .DS
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
RRECE 1P E
4.Date well(s)abandoned: • 3 -a- 3
rh
5a ell AJ I f1 1 gt7 �
location.
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
AJ
Physical AddreWCity,and Zip ignature ofQ r d'Well-Con or Well Owner Date
Nw G�ydy1W_ By signing this form,1 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.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
_(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
- N 7 ��- �� W You may use the back of this page to provide additional well site details or well
r/ abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable For multiple it jection or non-watersupply wells
ONLY with the same construction/abandonmenS you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: AAA_ abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 7 (ft.)
n 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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,
J 1636 Mail Service Center,Raleigb,NC 276994636
6e Outer casing length(if known): /" (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
/a of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): /, /" (R,) abandoned.
6g.Screen length(if known): N-A (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016