New Hanover_Well Abandonment_20231101

. i
is
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS I
Redox Tech, LLC 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:t@1s',t@2s',1@2s',t@2ti',t@22',r@2a',1©35'
3516-A r
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): n/a (gal.)
Redox Tech, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name . 7c.Type of disinfectant used: �.
2.Well Construction Permit#: Redox Tech, LLC
.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
• Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public , ❑Neat Cement Grout CI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout 0 Gravel
Ndn-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery.
• Injection Well: 7f.For each material selected above,provide amount of materials used: _
❑Aquifer Recharge LE Groundwater Remediation 150 lbs. bentonite grout
• ❑Aquifer Storage and Recovery ❑Salinity Barrier I'
❑Aquifer Test ❑Stormwater Drainage 1;
❑Experimental Technology ❑Subsidence Control 1, •
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Benseal bentonite grout to surface
R
4.Date well(s)abandoned: •10/5/23 ., Y r
•
5a.Well location: NOV ti 12023
Daikin Applied Americas, Inc NCD 057 451 270 i. • Iiii:;;, Il:-'.-:'�.s.}.., L
Facility/Owner Name Facility ID#(if applicable) 8.Certification: OW 1....7.L,C-1i.:)
602 Sunnyvale Drive Wilmington, NC 28412 ',Id'
. 10/23/23
Physical Address,City,and Zip . Signature of Certified Well Contractor or Well Owner Date .
• New Hanover 28412 1.
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County 1 Parcel Identification No.(PIN) accordance with 15A NCAC 02C.01'00,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: 1
(if well field,one tat/long is sufficient) I.
•
g 9.Site diagram or additional well details:
34.176774 N -77.935281 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
1
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS ;
• Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLYwith the same constructioruabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
•
• 6a.Well ID#: I P-1 through IP-7 abandonment to the following:
Division of Water Resourlces,Information Processing Unit,
6b.Total well depth: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
• 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: g
6d.Water level below ground surface: n/a (ft.). Division of Water Resources,UI derground Injection Control Program,
•
1636 Mail Service Center,Raleigh,NC 27699-1636
•
n/a 10c.For Water Supply&IniectioJWells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
address(es)above,also submit one copy of this form within 30 days of completion
. of well abandonment to the county jhealth department of the county where
n/a • abandoned. !
6f.Inner casing/tubing length(if known): (ft.)
•
6g.Screen length(if known): n/a (ft.)
•
Form GW-30 - North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
. I !