Lee_Well Abandonment_20230912

JELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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in clh <lit`lla'j� 7a.For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner pe sonally abandoning well on his/her property) well construction/depth 1 I GW 30'is needed. Indicate TOTALNUMBER of
t f wells abandoned: e i
NC well Contractor Certification Number 76.Approximate volume of water remaining is urell(s): q q. (gal.)
FOR WATER SUPPLY WELLS ONLY:Company Name t � I e of disinfectant used: 6u 1(r�n .1� ��'C h l0lt t7 �
2.Well Construction Permit#: '7 L 7i` �. q 3 r/ 7e —3 7c Typ
List all applicable xrfl ro»stnrction permits(i.e.U1C.County,State,Variance,etc)lfknown 2 �J
7d.Amount of disinfectant used, J
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply:
❑Agricultural ❑�Mitnicipa/Public ❑Neat Cement Grout GeBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑In du slriaUCommercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
I;0Irri ation
Non-watcr Supply Well:
IC-7 t.,, ti ❑Bentonite Slurry ❑Other(explain under 7g)
t ,Cj,4onitoring ❑Recovery -1.16jegttion Well: 7f.For each material selected above,provide anvmnt ogmaterja]Nuse
IlAquiferRecharge ❑GroundwaterRemediation Y J f Q�S
❑Aquifer Storage and Recovery ❑Salinity Barrier j J 81 -
❑AquiferTest ❑StormwaterDminage SEP 1 2 2023
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandon)tt$St�Ngdbr�f"•:'�+S•.'r.:�Uf3R
❑Geothermal(Closed Loop) ❑Tracer a ^.l,r,
❑Geothermal(Heating(Cooling Retain) ❑O1her(explain under 7g) "iHt �d �f�n !' 1 1fv'r/C(4t%✓tS ✓ '�rL
4.Date well(s)abandoned: ? �' �-A bap/` p ✓i, 1_� il�}rL�
y�(dJ'ts!s>` f 0: t�Ll rlrf -
Sa.Well loeationE " r
r lei tlAy�.
F(a}cility/OarnerNamef ,�j ( Facility ID#(if applicable) 8.Certification: fe �i
q 30 (-ion
Physical Address,City,and Zip -J -
Signature of Certified Well C4:66clor of well Owner Date
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By signing this./orm,I hereby certify that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance-Mill 15A A'CAC 02C.0100 or 2C.0200 JEW Construction Standards
and that a copy o,f this record has been provided to lire well onwer.
56.Latitude and iongitade in degrees/mtnutesdsetronds or decimal degrees:
(if well field,one latilong is sufficient) () 9.Site diagram or additional well details:
J,/ V �i�}'C \V You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUS<IITTAL INSTRUCTIONS
Attacliwellconslnrctionrecord(s)ifarailable.rornntltiplebrjectionernon-watersuppiritclls
ONLYwitithesameconstroction/abandonment,youcansubmitonefonn.
IOa.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: �'� abandonment to the following:
r Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5T-i"'}' (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the fonu to the address in 10a
6c.Borehole diameter• rn,) above,also submit one copy of this fonu within 30 days of completion of well
abandonment to the following:
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bd.Water level below ground surface: (ft.) Division of Rater Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6c.Outer casing length-(if known): ` (ft.) lOc.For Rtater Saaaly&Infection Wells: In addition to sending the fonu to tine
address(es)above,also submit one'copy of this form within 36 days of completion
of well abandonment to the county health department of the county where
6f.Inner casingitubing length(f known): (ft-) abandoned. t
6g.Screen length(if known): ru (ft)
Form M-30 North Carolina Department of Environmental Quality-Division of water Resources Remised 2 22 2016
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