Randolph_Well Abandonment_20230915

VY J!L,I1 AtsANDUINMENT RECORD For internal Use ONLY;
1, ell Contra``�tId io
r Information: WELL ABANDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor a o Na r well owner personally ohm:aloning well on bistherpropeay) well construction/depth,only I GW-30 is needed.!Indicate TOTAL NUMBER of
awells abandoned:
1
NC Well Connector Cenificai n Number 7b.Approximate volume of water remaining in well(s): (gal,)
Q.0 , L. OQttt1G-3 9 1Na
FOR WATER SUPPLY WELLS ONLY: '
CompanyName '
lc.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well canstruciian permits(i.e.UIC,County,State.Variance,etc)ifiawwn 6.,7...-
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: ,7e.Sealing materials used(check all that apply):
❑A cultural
❑MunicipallPublic 0 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) tgResidential Water Supply(single) 0 Sand Cement Grout ❑Dry Clay
❑lndustria1/Commereial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well:
0 Bentonite Slurry 0 Other(explain tinder 7g)❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,��•Recharge � provide amount of materials used:
❑A
q ❑GroundwaterRemediation 3 I * . 5 W e!( G1a. -&
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) pTracer 7g.Provide a brief description of the a aba4ej4c
onment procedure:�
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) C l btu\N Pk W'e`l) ' `i V61��1p1
t.
4.Date Well(s)abandoned: 1 —` — �( F, Cr-R w i 1)I h wet w��� GRD1.lT I.17 la, �e�1/l7V G
i
�--r a� ao sass..)I �Pi,u�.d 51E s 1/Zi•
�N i tv S E P 1 2023 c'o tic t:.�,p
Facility/OwnerName .. •- iFd �r-`f c ' .. , .
Factht}idi"(iEhjrphcaBte) :�:'cg. ertifieation j///�/�J./}... ::
qOl tic eN ��e�tr�ace, arJ0 n�-k0,1_,,,..20 c...
Phyyyy����ical Address,City,and Zipig
9 r r��
I.Ei� it y I .. Signature ofCertified Well Contractor otWeli Owner' Date�1 By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with;j5A NCAC 02C.0100 or 2C.0200 Well Constriction Standards
Sb.Latitude and longitude in degr ees/minutes/seconds or decimal degrees: and that a'copy'of this record/ws'been provided'to the well owner.
(if well field,one lat/long is-sufficient)
2 L�t 1 15 3q N N 7 • ??11G 5 9.Site diagram or additional details:
�J `' O W You may use the back•af this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach well construction records)ifarailable.For:maple infection ornon-watersupplynulls SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment you con subm'-i one form. - -Da. For For All Wells: Submit this form within 30 days of completion of well
6a.Well IDtr: . abandonment to the following:
t�I. .
.Division of Water Resources,Ir forunition Processing Unit,'
6b.Total well depth: - (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
p 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. (in,) above,also.submit one copy of this.form within 30 days of completion of well
abandonment,to the following:•
a.
6d.Water level below ground surface: `n (ft.) Division of Water Resources,Underground Injection Control Program, ,
. • .. . • 636 Ma
il Service Center,Raleigh,NC 27699-I636 . '
be Outer casing length(if Imovy�:' 10c.For Water Supply&Injection 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
61 Inner easing/tubing'length(iif'mown): (ft.) abandoned: .
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016