Polk_Well Abandonment_20231006

RECEIVED
WELL ABANDONMENT RECORD For Internal Use ONLY:
SEP 172023 i ;
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Garry Coomer NC DEQ/OWP 7a.For Geoprobe/DPT or Closed(Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on coliteggrafice well construction/depth,only 1 GWi 30 is needed. Indicate TOTAL NUMBER of
2164-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Coomers Well and Pump FOR WATER SUPPLY WELLS ONLY:
Company Name chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)ifbtown 15 oz
7d.Amount of disinfectant used::
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Gro.t. ,_, _ _ IA Bentonite Chips or Pellets
['Geothermal(Heating/Cooling Supply) ❑Residential Water.Supply(single) 0 Sand Cement Gr ii `- ( - -`='ii ,,/t❑'Dry Clay
•
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
sUrigation 0 Specialty Grout O C T 0 G 2Q211 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery InwriC•-'a±t:,.n 1 r•.--C•:a as3 1.%n?
Injection Well: 7f.For each material selec{eMabove;p'b vide amount of materials used:
❑AquiferRecharge ❑GroundwaterRemediation 12 bags sakrete
0 Aquifer Storage and Recovery ❑Salinity Barrier
['Aquifer Test ❑StormwaterDrainage 112 bentonite
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
filled well with bentonite pellets(hole Plug)closed 112 bags 501b
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 9-6-23
5a.Well location:
•
Eugene Kilbey
Facility/Owner Name Facility IDb(if applicable) 8.Certifica• n:
44 Mimosa Road, Columbus, NC ("1/)"- - V z_y
Physical Address,City,and Zip Signature o Certified tractor or Well Owner ate
Polk
By signing is •fo n,I hereby certify,that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance • 5A 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:
(if well field,one 1at/long is sufficient) 9.Site diagram or additional well'details:
35.23925 N 82.23670 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
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##: n/a abandonment to the.following:
Division of Water Resources,Information Processing:,=nit.
6b.Total well depth: 93 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24" 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:
6d.Water level below ground surface: 62 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): n/a (ft.) 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
6f.Inner casing/tubing length(if known): n/a (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