Chowan_Well Abandonment_20231006

WELL ABANDONMENT RECORD For lntemal Use ONLY*
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1.Well Contractor Information: NWLL ABANINDA 8NT DETAILS
7a.For GeoprobdDPT or Closed-Loop Geothermal Wells having the same
we�ntractor Name(or well owner personally abandoning well on hisTherpropetty) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned- I '
NC Well Contractor Cortification Numkua 7b.Approximate volume of water remaining in weli(a):
4-M r, K.)Cif 4 g 1„^7L( 1 CJ h/1 FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.TypeofdislnfectaAtused: G'A�Li'vui �4Yfm�tco�� rE
2.Well Construction Permit#:
ataflapplicable wall constriction permka A M,,C600.Stafe,irarionce,etc.)If/mown 7d Amount of disfnfeCtant used:
3.Well use(cl=kIvell use);
Water Supply Well: 71-stain md"hs%Vftd(c'hct3tA(Orit
DAgticultural t7MunicipaUPablic ❑Neat Cement Grout _ i �PL�entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ❑Sand Cement 'v Y.6 TY Dry Clay
❑Induslrial/Commereial Oltesidential Water Stipply(share d) ❑Concrete Grout r' it fup Drin cuttings
13rai O'Specialty 0rout O C T p G 20233 Gravel
Non-Water Supply Wen: 0 Bmtonite Slurry 17 Other(explain under 7g)
i7Manitotiu ❑RecoYesy lrk'i3TTf' :f^i1 1�5 e�$,GT?i?:�'1 lil;�Injection Well., 7f.For each materiel selei;tt4000prov(iie amount of materials used:
DAquifer Recharge OGroundwater Reme diation
C7Aquiltr&omp and Recovery CSatnwHarsier
OAquifer Teat QStormwater Drainage e2�a �'t'1 Gr S
OEVerirneutal Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
t7Geothermal(Closed Loop) ]:]Tracer �
❑Geot her mal(We atin&Coolin g Retum) OOther ex lainunder7 ) 'LC'G' 't✓ W Ott bL LL V;6E G✓i r•?�a.t
/ �t-TAke Stta-r:c �iblf-iC� t It�+ttf, 5GJN�iIIC§a
C Fo&L `JN t4.
4.Date well(s)abandoned- I^�1 T:.O a.25 CbtCaY'��NA'Crc v4ew- 1 13t-Ck t=:'L.G WIT,-t
FnCuity/O.-Nano FaetIIty]D#Ofoppikable) S. 'erifficaflont
s 3 7 RA*-44 b,sl-_ Rr1_ nJ.c. ?,,� c,t� l` V
Physical Address,City,andzip A`7?3.;. Si tare of certified Walt Contractor or well Owncr Date
Gir4 ,JdJ,i.i
By signing this form,!hereby ceriO that the tve11(s)was(were)abandoned in
County �— Pared Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
nrad.tt vaCappcy*rhapmardAW bempvoWed to.Fhe;WIIVWW
5tr Lathude and hmotedeIndegmWndaut+ev/,w ndsor decimal degrees
(ifwell field.,one hmung is sufficient) 9.Site dlagmm or additional well details:
Q � N .--�� S g 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 If necessary.
CONST-RUCTION DETAILS OF WELL(SI BEING ABANDONED 5U11MITTAL IlVSTRUCTIONS
Artachwe8eanrtmctlonrerord(s)#Iamilable.Parmulrtpkinfecdonorrron-watersuppi),llwr
ONkYwifhdiesmaecooft7lon/abandonment,you can w6miraneform. 10a. For All,Felh Submit this foam within 30 days of completion of well
6n.Well Mg: all
abandonment to the following:
Dhv*m oS Water Ykeaom%%S,9nforarhirm litrutmbgums%
6b.Total Well depth., 16171Fi, So-Ace Svice Center,RaIdgI4WC 27699-1617
10b.For Iniectfon Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: A (ln,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following,
6d.Water level below ground SUrfaelt�___ .. ([t,) Division of Water Resources,Underground fniection Control program,
1636 Mail Service Center,Raleigb,NC 27699-1636
..`•."""..",. - "` -'-•. , adtims(es above also submit one c of ibis form within 30 days or completion
he_(lntar casino Innoth rif tmmun\: C/�(\�'A�ri c?J,t.,d�fft3 ��' - 1
a Inner casing(tubing length(if)mown):�( (ft.) abandoned '
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6g.screen length(if lotown): k(yG t A)& (ft.)
Form OW-30 North Caroft Deparmal of Bnviroameatal Quality-Division of WaurRCwmcs Revised 2-22-2016
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