Wayne_Well Abandonment_20230818

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
ralph lawhorn 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 constiuction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
2671 a wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3gl (gaL)
ralph lawhorn well'drilling FOR WATER SUPPLY WELLS ONLY:
Company Name
� y 7c.Type of disinfectant used: C Ori n e
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)rflmown 1/2bl
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Mimicipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) PResidential 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: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1/4 of bag
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) drop chips i n till full
"�r -% t
4.Date well(s)abandoned:
8-10-23
Sa.Well location: ��J
wayne county rPhr� 'f
Facility/Owner Name Facility lD#(if applicable) S.C i cati
2290 s nc hwy 111 �.� �. 8-10-23
Physical Address,City,and Zip Signature ofC4&fied Well Contractor or Well Owner Date
wayne
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 guffrcient) p 9.Site diagram or additional well details:
1
N W You may use the back of this page to provide additional well site details or well
/ I abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Artachrvellconstructionrecord(s)ifavailable.Formultipleinjecdonornon-watersupplyxells
ONLY with the same constructionlabandonnient,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,
6b.Total well depth:20 ft (ft.) 1617 Marl Service Center,Raleigh,NC 276994617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 1 1/4 (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• 10 ft M.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length Of(mown): 20ft 00 10c.For Water Supply&Infection Wells: In addition to sending 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
611 Inner casing/tubing length(if known): 0 (N abandoned.
6g.Screen length(if known): aft 00
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016