Union_Well Abandonment_20231006 (2)

WELL ABANDONMENT RECORD For Internal Use 01.E'z•:
I � •
1.Well Contractor Information: WELL'ABANDONMENT DETAas,
7 7a.For Geoprobe/DPT or Closed-L;oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hivher property) Well construction/depth,oaly kQW 30,is needed. Indicate TOTAL NUMBER of
2 wells abandoned: Iwo'
NC Well Contractor Certification Number 7b.Approrzmate volume of water remaining in well(s): (gaL)
EhVjY,rnw+ A"J rJrtAt 4- PJ6WV-J SEMkfl (CC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit tit: �
List all applicable well construction permits 6.e.UIC.County•,Stare,Variance.etc.)if knoum
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materWs used(check all that apply):
❑Agricultural ❑Municipal/Public ticat Cemeni-Crr tit4 � M';r^ ❑_Bentonite Chips or Pellets
❑Gohthermal(Hpting/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout k..'A„ �:�J•O..DryfClay
❑Industrial/Commercial ^Residential Water Supply(shared) ❑ Concrete Grout OCT ❑ I%b Cuttings
❑I rri ation + ❑ Specialty Grout 0 C' 2023❑Gravel
Non-Water Supply Wen: ❑ Bentonite S] ,t;�_
.. � V_ ❑Other(explain trader 7g)
DMonitoring ORecovery
Injection Well: 7f.For each material select ve,+'provide amount of materials used:
OAquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery GSalinity Barrier
Aquifer Test CStormwater Drainage
❑Fxperimental Technology 0-Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) CTr•acer 1 I t
❑Geothermal(Heating/Cooling Return) ❑Other(explain under?g) 1 MP W s wem ' Mr WVQA JCi�
t9pOY1 Sa0.Yu���t`6u4 CflrNP�t2. ►1� Ct�4bltME� �ytlld� Up}}�M
a.Date well(s)abandoned: q' z Z—t 3
w1 wed w` ce+n►etnt� 4- 8fWAA
5a.Wen location: lwrfoice neh to vwrM4 1Vy1dAj}a(1S.
S1�vppirq Cev►� •
Facilirv/Owner Name Facility IDa(if applicabler 8.Certification:
+, o� Mt,Ic ,'1le g1vd. rn5i: r uvShvi►le
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Physical Address.City.and Zrp C, Signature of Ccrtifilrd Well Contractor or,Well Owncr Date
11 Y►i d►'►
Bt�signing this jotm. 1 hereby cerrifi, that the xelils) was.(tver•eJ abandoned in
County Parccl Identification No.MN) accordance with 15.4 MCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this,record has been provided to the utll owner.
5b.Latitude and longitude in dcgreesiminutes/seconds or decimal degrees.
rifwel!field one lavloag IS sufficient) 9.Site diagram or additional well details:
You may use the back of this page.to provide additional well site details or well
N W abandorment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAELS OF WELL(S)BEING ABAINDONED SUB?I CTAL INS1'RL'CI')ONS
.(mach well conrrmcrion mc-otdts)rfawilable For multiple injection or non-eater supph•%oils
ONLY with the same cons�mrjclioniobandanment. »v can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# a 1 ev T-1 abandonment to the following:
Division of Water Resources,Information Processing Unit, ,
6h.Total well depth: '40 (Rs,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection'Arells: In addition to sending the form to the address in 10a
6c-Borehole diameter: (�,j above, also submit one copy.of this form within 30'days of completion of well
abandonment io the folloi)-ing-
t Division of Water Resour ,'Liude rotmd Injection Control
6d Water level below ground surface: ( ) cesProgram166 Mail Service Center Raleigh,NC 27699-1636
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6e.Outer casing length(if known): N 1'} (tit,) 10c.For Water Sunal%&Iniectiti'n Wells: In addition to sending the form to the
address(es)above.also submit onc'copy of this form within 30 da)s of completion
of well abandonment to the county health department of the county where
6L Loner casing/tubing length(if known): ?✓� (ft.)
abandoned.
i
6g.Screen length(if known): i O (R) i
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Form GW-30 North Carolina Department of Environmental Quahty-Division of Watcr Resource' Revised 2-22-2016