Wilkes_Well Abandonment_20230818

'WELL ABANDONMENT RECORD For Internal Use ONLY:
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Well Contractor In ormation: WELL ABANDONMENT DETAILS
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r 7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
We:i Contractor Name(or w 11 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.)
YADKIN-WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company Name
- 7c.Type'of disinfectant used: V'
2.Well Construction Permit 9: 08 0 L
List all applicable well construction permits(i.e:UIC,County,State,Variance,etc.)ifk.nown
7d.Amount of disinfectant used: 1�L
3.Well use'(check.ri•ell use):
Water Supply Well: 7e.Sealing materials used.(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grow \i= 'I["'f �.Be�onite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) fitesidential Water Supply(single) 0.Sand Cement Grout cz I �'E&Qlay '
❑h:dustrial/Commercial ❑Residential Water Supply(shared) .ncrete Grout AUG 1 L O q04 Drill Cuttings
Obligation ❑❑Specialty Grout O Gravel-
Nod-Water Supply Well: 5-<ntonite Slurry sur;7V h ♦1 ter(explain under 7g)
Monitoring ❑Recovery D1P,`C zo
;.ri.:r_tion Well: 7E For each material selected above,provide amount of materials used:
i.,quifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑salinity Barrier'
❑Aquifer Test ❑Stormwater Drainage
❑Ei:perimental Technology ❑Subsidence Control. 7g,Provide a brief description of the abandonment procedure:
❑Geotherrnal:(Closed Loop) ❑Tracer - �``' �'
❑Gt:otheama4,(H:eating/Cooling:Relum).. . ❑Other(explain under 7gtJ tt'�1*+Iru� 1/l`Y', - `tP. i Yt.
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4.Date well(s)abandoned:
Sa.Well location: '' f /� / rty�/ (50 / J /tit
�/y� l/G9/•1/!a SSG yn�A 7'In '. i/c/1�t_/ PJT.�-. /U I
Facility/Owner Name Facility IDl/(if applicable) 4Certhiion:
Physical Address,City,and Zip �rK 'A. �{�t�t �( enifie 'Con cto or Well Owner ate
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By signing this fotm, 1 rera y certify that the wells) was (were) abandoned in
Cou•ty 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 ivell owner.
.-i.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
fwdpll field,one Iat/long is sufficient) 9.Site diagram or additional well details:
11 95 3 ( N _9 b i 1N QS19 gi 1:C W You may use the back of this page to provide additional well site details or well
4Ci 1. 'd abandonment details. You may also attach additional pages if necessary.
CONSTRUCTIONDETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auach well construction record(s)tfovailable.For multiple hjectionornon-water supply wells
ONLY with the same consintction/abandottrnent,you can submit one form.
10a. For All Wells: Submit this form within 30;days-of completion of well
6a:1Vel(ID# ' abandonment to the following:
,ram Division of Water Resources,Information Processing Unit,
6b.;rotal well depth: 6 ?0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells:. In addition to sending the forrti to the address in 10a
6c.Borehole'diameter: (iu.) above,also submit one copy of this-form within 30 days of completion of well
abandonment to the following:
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6dJW, ater level below ground surface: C J (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): Cl l. (ft.) loc.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
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
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62.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016