Rowan_Well Abandonment_20231006 (2)

WELL ABANDONMENT 1 RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
pwwh ' jJ 0 F 72.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor 1 ame(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 130 is needed. Indicate TOTAL NUMBER of
wells abandoned: I
A51a - C
NC Well Contractor Certification Number 7b.Approximat e volume of water remaining in well(s):_ (gal.)
Morgan Well & Pump, INC FOR WATER SUPPLY WELLSIONLY:
Company Name 7c.Type of disinfectant used: granulated chlorine
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if)Drown ?
7d.Amount of disinfectant used.; J Q 2
3.Well use(check well use):
Water Supply Well: 7e:Sealing materials used(check all that apply):
❑Agricultural ❑�Municipal/Public ❑Neat Cement Grout r• 7 W<entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) [illitesidential Water Supply(single) ❑ Sand Cemen �" '❑"Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Con re
Groat n n n ❑Drill Cuttings
❑hrigation ❑ Specialty Grout �C� d 2Q2� [IGravel
Non-Water Supply Well: •0 b' then(explain under 7a
PP Y ❑Bentonite Slurry ���•:, •'^�••• ( P b)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation q601Q
❑Aquifer•Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer y,�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 1�/,� //2/"e f kc /.Lye le , �ijl•P.d 6�UTAA �OCll/GII/(T
4.Date wells)abandoned: q [.�
-p P
Sa.Well location:
191le 5�/0
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3 !:z _ "ncr�o�
Physical Address,
City,and Zip $ign -e of Ce e oWell retractor- r Well Owner Dat
ga� /Sum 7 By signing this form, I h r2by ceitify that the well(s) was (were) abandoned in
County 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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long insufficient) 9.Site diagram or additional well details:
7 q You may use the back of this page to provide additional well site details or well
�L5 N b T,,(l'? �t abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.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#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
I 1617 Mail Service Center,Raleigh,NC 276994617
6b.Total well depth: ` (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this,form within 30 days of completion of well
6c.Borehole diameter: J9 (in•) abandonment to the following:
6d.Water level below ground surface: i,d (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): k (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): Jr (ft.) abandoned Z '
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource) i Revised•2-22-2016