Moore_Well Abandonment_20231024

WELL ABANDONMENT RECORD For lnienia'UsdONLY;
This faint ran be used.for single.o r multiple wells
1.Well Cnntractur Information: ��� WELL ABANDONMENT DETAILS
Robert Miller -7a,Nhnibcr of wells being abandoned: 1 .
Welt Centractor Name.(Or well oxtwvpec4dsully:abam[gsilir;ttal.on!limiter praperty) Ftir n:ufnpk inlirttae a• rwri-'infer supllh. wells• .ONLY with the some
con irita itthaelmrowitL)rnr our rdt orr4j rru,
2675-A
NC Wcp Coniraaar Ccitiftcaliutr Nnrrsbcr 74.Approi:imate volume of Brat I^r inaining in w II(i): (gal.)
SAEDACCO FOR.WATERSUPPLY WELLS'
L ONY: •
Canny Nano. 7c,Type of disinfectant!tied:chlorine tablets . . •
2t WellCanstntctinn.Perinit 14:97212, _,
Laifdlaiiplttrtkleielllarmrts(ill.Coarih:Sie:i.iarliir:ee.lijrdlorr..r,clffdsmwo Id.Amount of disinfectant useai:3 OZ •
3.Well uir(cited:n'clt use): '
Water Supply Well: .7e.Sealing inaterirlsused(cbectc all apply):;
❑Agm ultttell CIMitnicipal/Public El,Neat Cemcot.Giuiut Cl 13cntoiiitc Chips or Pellets`_
ElOeothcrosal(Renting,'Coolin&Supply) •.'<Residential Water.S ipply(single) El Sail Centertl Grriut ; ❑Dry Clay
❑htdnsirial/Commercial ORcsidential Water Supply(shared) O Coincnte'Grout t, O Drill Cuttings
Ohdetion • _ O:Spec:ialty Grout: . • ; C Grar"el
'Non-WaterSupp1yWcll , El Bentotule5lnrrz CI Odier(erplain'under7g)
. [Monitoring-_ _ t7Reepsell,. , . • .
•
Injcctiop Well: 7f-.For each material selected above,provide amount of.mater'ials used:
.OAilulfer Recharge OGruuiidn;tler Rentediation Neat Cem. 2,5001b ,Wtr•175ga1. Sand,Cem.:lb ,Wtr•gal.
DA'quifer Storage and Reijovere DSalnrit;Barrier`-
ClAintifit Test OStonnnater Druitnnie
Bentonite.:401b ,Wtr:gal. •
DEspeiiuir:ttlal Tecluttitogv OSubslc[e r Carttrnl 7g.Provide a brief dciicriptian of the abandonment procedure:
CJGeotherinal(Closed Loop) ClTracer .
Using 1" pvc trimi pipepump grout from bottom to top:
ElGeothermal(Healing/Cooling_Retu_rn) .C3Gther(explainunder731
displacing water from well.
•
3.Date w'cll(s)a►handnned: 9-19-2023 ' "`T° 7 ,+ ,r,TM 'n•
5a.)Yell location:_ ({
Arnold's Corner - - - O C T 2 l 2023
Fatilitrtr3tvttcrNurne Fxility 1Ds(iapplicablc) 8..fe•tiQcatitin: .
:47?0 ,2i
907 US.15-501 Hwy.. Cameron, NC.28326 i �'J>( ''L9%25/2023
Plti�sical Address.City;and Zip Sigratt:'c o''"'^.�•:r.^: :t Zfi::'ft. !i 'tent DADS
Moore try sigring this form, 1 hereby-cei-tir•that lire well(s) was(were)abandoned in
Caiuty Parcel ldenlitteatinit No.(PIN) ikro iltnace:it•ith/54.\CACO2C;0.I00.or2C.0200le'ill Constiuction Stainkmis
anti that a copy oftlris ivcord hasbeen provided to he tieli thiiier.
Sb:J ttitudeaud lougita.ite.in degrees(nunutes/seconds or decimal-degi+ctsi
(iitieil t`tekl,one lattloh :is saillekti) - 9.Site diagram or-additional well details:
You may.use the back of this page to provide additional nen.site details;tot well
• N W abaudoimtetii details:You may also attach additional pays if necessary..
1
C(1NSTRUC'TION.bETAiLS OF.WELL($t BEING ABANDONED SUBMTFTAT.INSTRUCTIONS'
:moo oo well colzxn relied!fi vrd(S)of nib]Wh'i. I or onrhtple it feat itch.W•ronnrater.wpplr I1.
welts ONLY with flan'somerntrstrooltht.c Ltnerhilrr Oi,ieto von=briio rare fern
10a;For All Wells: Submit this.tart within 30 riays of completion of well
• 6rt.�Yel1 ID€1:wsw-i abandonment to thcfoltbwin - •
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I'
Divisiunof WaterRrsour•cec,Information Processing Unit;
196 1617 Mail Service•Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) 1
lob.For Iniection WellS: In addition-to sending the fonn.to the address iu l0a
6e:8orebole dL�nteter:6 ((n;) above.aiso submit one copy of this form within 30 days of completion Of well
• tlbundotuneut to the following' 1
6d.Water tetci below ground surface;25 (ft) -Dlrislou.af Water Resources underground Injection Conttvl Program.
1636 Mail Service Center;Raleigh,NC 27699-1636
6c..0utcr easing le • 10e.For Water Sunnis•&bileetiote Wells: hi addition to sending the form to
g length(if known)• (ft,) the'address(es)-aboye. also subdritj one copy of this bon Within 30 days of
completion of well abandomnentko!the county health department of the county
6f.Inner easing/tubing length(if known): (ft.) where abandoned, i
6g..Sereen length(If known): - (ft.) '
• • Form GW-30 North Carotlm Department of Ernironment and Natural Resources-Division of Water Itei.outees Revised August 201i-