Wayne_Well Abandonment_20230818 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
L 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 construction/depth,only 1 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 p y Name 7c.Type of disinfectant used: CI Orme
2.Well Construction Permit#:
List all applicable well construction permits(.e.UIC,County,State,Variance,etc.)ifknown 1/2 bl
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agrictiliural ❑Municipal/Publie ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industtial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Olrrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: _ ❑Bentonite Slurry ❑Other(explain under 79)
❑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 El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer drop chips in till full
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 8-10-23
c AUG
5a.Well location:
wayne county
Facility/Owner Name Facility ID#(if applicable) 87ce n:
402 oak st seven springs nc 8-10-23
Physical Address,City,and Zip Signature of dffled Well Contractor or Well Date
Wayne 1,
By signing this form,I hereby certify th the well(s) was(were)abandoned in
County 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:
(ifwell field,one latnonV sufficient) 9.Site diagram or additional well details:
�'/ _b� U N 7- Q y W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection ornon-watersupplywelis
ONLY with the same construction/abandonment,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 00 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 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 20ft (R) 10c.For Water Suaaly&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
6E Inner casing/tubing length(if known):0 (N abandoned.
6g.Screen length(if known): 3ft (ft.)
I
Form G W 30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016