Union_Well Abandonment_20231024 (3)

WELL ABANDONMENT RECop.,D For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well on acor normat
C/y � t If ip� WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
Well Contractor Name(orwell owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY with the same
constructiaWabandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): !O (gal•)
FOR WATER SUPPLY WELLS ONLY:
Company Name -
7c.Type of disinfectant used:
2.Well Construction Permit#: —I-X-)
List all applicable well permits(i.e.County•State,Variance,Injection,etc.)if!mown
7d.Amount of disinfectant used: Z A'n S
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout _ ILL-Rentonite Chips or Pellets
❑Geothermal(HeatingiCool'tng Supply) t ential Water Supply(single) ❑ Sand Cement Grout r__ ';—s„ %=l,•'UN'Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑D"nll Cdttings
❑Irrigation ❑ Specialty Grout 0 C T v / Z p2Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ORecovery
Injection 1Ve11: 7E For each material selectcdFtiti'ove;proZide'amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2'Z
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer❑G � �
eothermal(Heating/CoolingRetum) ❑Other(explainunder7g) og
4.Date well(s)abandoned: 911 3( 2
5a.Well location:
Facility/Owner Name nn FacilityID#(ifapplicable) S.Certif;cathm:
q b�l Gill'��1P �oG� M.41�vs �1/G Z810 9,f 23
Physical Address,City,and Zip /yam Signature ofCerdfied Contmc or well Owner Date
l U�1vJ U�� By signing this form,I hereby cerhfy that the 1ve11(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance ivith 154 NCAC 02C.0100 or 2C_0200 Well Contraction Standards
and that a copy of this record has been provided to the ivell owner.
56.Latitude and longitude in degreec/minntes/aeconds or decimal dcgrccs:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
3 S, (2-7-19Z N - D You may use the back of this page to provide additional well site details or well
Rr abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(SI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cotunttction record(s)if available. For multiple ityecamr or non-water supply
wells ONLY with the same cotuuvctioulabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#•_ 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth .5 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
9 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 10 above,also submit one copy of this forth within 30 days of completion of well
(In.) abandonment to the following:
6d.Water level below ground surface: f r (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fk) 10c.For Water Sunnly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit,one copy of this fort within 30 days of
completion of well abandonment to,the county health department of the county
6f.Inner casing/tubing length(if known): AAP
_(g) where abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL 1BAND®NMEENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I. el Contractor Ia ormation: WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
Well ContractorName(orwell own personally abandoning well an hislher property) For multiple injection or non-voter supply wells ONLY with the same
constructionlabandonmenl,you can submit one form.
NC Well Con ra�ctor\Ce`rtificlation Number l 7b.Approximate volume of water remaining in well(s):_ _(gal,)
' ° ►�L W�V�j �1/1 1 �1,� FOR WATER SUPPLY WELLS ONLY:
Company Name
7.Type of disinfectant used: �-•+'
2.Well Construction Permit 9:^ tit ICJ
List all applicable well permits 6 e.County,State,Variance,Injection,etc.)f/mown'
7d.Amount of disinfectant used:_ 0-,-- 5
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural aVPublic ❑Neat Cement Grout
❑MuniciP _
onite Chips or Pellets
❑ �GGeothernal(Heating/Cooling Supply) [JResidentiat-Water Supply(single) ❑Sand Cemen out•'—,'T `' a;i'�"d.Dry Clay
aJ l„;I
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout `❑'Drill Cuttings
❑Irri ation ❑Specialty Grout C T 2112� ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery ,_�,•- ;f:3 !-.'t .•
Injection Well: 7E For each material sFelected.alio'vc,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation >8 S
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the a andonment procedure:
❑Geothermal(Closed Loop) ❑Tracer t
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �kCG �� P� 0� -/-1,,B 0 I-H 1
4.Date well(s)abandoned:
5a.Well lotion: i �
Facili vnerName Facili ID#(ifapplicable) 8•Certificati
3��L( Lttc-z k o\ I eyy'6G �1/C 24
9h2v z 3
Physical Address,City,and Zip Signature ofCe cd W II Contractor or Well Owner Date
U�1 `�� By signing this for , I hereby cerhfy that the ivell(s)was'(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
$b.Latitude and longitude in degrece/minutes/seconds or decimal degrees: and that a copy of this record has been pros ided to the well owner.
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
-15 . (15 Z / N��Q, Z3�p You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLfj BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or nor-water supply
wells ONLY with the same cottstrttctiot/abatdonnnent,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,
6b.Total well depth: �� (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
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: 0 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): �/ A) the
For Water Supply&Iniection 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
6f.Inner casing/tubing length(if known): v l'Y (ft) where abandoned.
6g.Screen length(if known): (ft,)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013