Rowan_Well Abandonment_20231101

1.W ntractor formation: WELL ABANDONMENT DETAILS
7a For GeoprobefDPT or Closed=Loop Geothermal Wells having the same
Well Contractor Name(or well ovmer personally abandoning well on his/her property) well constmction/depth,only 1 GW30 is needed. Indicate TOTAL NUMBER of
wells abandoned:� � : •
i
NC Well Contractor Certification Number 7b.Approximate•volume of water remaining in well(s): (gal.)
Morgan Well & P u mp,d N C FOR WATER SUPPLY WELLS iONLY:
Company Name 3 ra�nulated chlorine Q Q g� I 1 7a Type of disinfectant used: g I
2.Well Construction Permit 4: 1 J
List all applicable well co»s•A•uction permits(l.e.WC,Count),State, Variance,etc.)if known �^�
7d.Amount of disinfectant used:! U
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mimicipal/Public ❑Neat Cement Grout X Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 4,Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared)- P Concrete Grout ❑Drill Cuttings
'❑Irrigation Cl Specialty Grout ❑Gravel
Mn-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For ea h material seleAped above,provide amount of materials used:
❑Aqu O Wifer Recharge ❑GroundwaterRemediation Q G16�i
❑Aquifer Storage and Recovery ❑Salinity Barrier li �
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ' v-
' 7g.Provide a brief_descripti n of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer "~ h I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g). ••".=%= `OT'�� C 1� v ���U
1 2-
4.Datewell(s)abandoned: {�� J0— bJ�a �S �,fi � ��1 f t'�,
"r`
5a.Well location: A
Facility/Owner,Name Facili ID#f(if applicable) 8.Certifi n:
(JWI f- $ r'Sb>r r1 Nov ; zn -3
aAddress,City,and Zip Pa
tca Signature of Certified Well Contractor orh'Ownei '- -. : Date
ula� z
By signing this form, I hereby certify that the well(s�was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 154 NCAC 02C.0100 or 2C.0200 Well ConstructionStandards
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:
(if well field one laUlong is sufficient) 9.'Site diagram or additional well details:
N _� 31 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.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMPTTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-water supply wells .
ONLY with the same construction/abandonment,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:
t Division of Water Resources,Information Processing:Unit,
6b.Total well depth: (ft) 1617 Mail:4irrvice Center,Raleigh,NC 27699-161 '-
�J .,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
n abandonment to the following: 4I
6d.Water level below ground surface: r i (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): /V/I (ft.)' 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of-ompletion
of well abandonment to the county health department of the county where
_ 6f.Inner casing/tubing length(if known): (ft.) abandoned
6g.Screen length(if known): 04//P (ft
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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