Union_Well Abandonment_20231024 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Weld actor Info nation: WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
Well Contractor N r well owner personall bandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
constructimr/abandonmeni,you can submit one form.
J
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
11 �( L� FOR WATER SUPPLY WELLS ONLY:
Company Name
� � 7c.Type of disinfectant used:
vl2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Foriance,Injection,etc.)ifknown I C
7d.Amount of disinfectant used: 1 J
3.Well use(check well use):
Water Supply Well: le.Sealing materials used(check all that a ply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout _ Mntonite Chips or Pellets
❑Geothermal(Heating/Coolmg Supply) Residential Water Supply(single) ❑ Sand Cement Grout t. 'a,f, •//�fp��``Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout O C 1T r 1: ,2023❑Gravel
Non-Water Supply Well: ❑Bentonite Slurr
t1y _ ❑ Other(explain under 7g)
❑Monitoring ❑Recove I , 1 3 ur
Injection Well: 7E For each material selecte&Adve,orovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation `� )
❑Aquifer Storage and Recovery ❑Salinity Barrier lU
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) —�X�Cl a^' 31 •✓e OL►-1
0_0r1=11- C-�-Si cu �
4.Date well(s)abandoned: f
vt. G
43
5a.:.Wseg location:
D - �
Facility/Owner Name �Fac'1' ID# 'fapplicable) 8•Certific 'O
Lip � � ����� fe. _ a�a3
Physica l Address,City,and Zip (� Signa of Ce "fled Well Contractor or Well Owner Date
L)f
i L/ By signing! is form,I hereby certify that the ivell(s)lvas(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
$b.Latitude and longitude in degr•eec/minates/seconds or dec:mol drgrccs:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
65` N '01 `bT UU q c W You may use the back of this page to provide additional well site details or well
_I abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Ailach well construction recard(s)if available. Far multiple injection or non-wafer supply
wells ONLY with the some construction/abandamrent,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:
1 Division of Water Resources,Information Processing Unit,
6b.Total well depth: I (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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: (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sunnly&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
6E Inner casing/tubing length(if known): (ft) where abandoned.
1
6g.Screen length(if known): (ft_)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Rcs'ources Revised August 2013