Moore_Well Abandonment_20231113

WELL ABANDONM1 �� RECORD Far lntemal Use ONLY`
I
1.Well
ContractorCo Information: ,, ,/ /� WELL ABANDONMENT DETAILS
L d/ 1+_2!�f�Iq t+� 1�11 • 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally aband ing well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I
NC — ,.23734I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
il
G-ra AS C,,, ,�, i),•vws.`..'Qd sa.,.ft.( k^q FOR WATER SUPPLY WELLS:ONLY: „„ _._ : .;,..,`
Company Name i' NOV
P y 7c.Type of disinfectant used: )4 T i Y 1 /�q ',
2.Well Construction Permit#: 2023
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:, 1a 03
3.Well use(check well use): �;,3 fN,e
Water Supply Well: 7e.Sealing materials used(check all that apply.):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout t'Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 1 idential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
I7lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite_ Slurry ❑ Other(explain under 7g)
❑Monitoring . ❑Recovery — — —
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation j et S f�"l !/k�i
❑Aquifer Storage-and Recovery ❑Salinity Barrier J T/V
❑Aquifer Test ❑StormwaterDrainage _
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Clay.
� n
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Clay. IN c,: l JJ J . ?Add Ni'
�f _i111-7 sa..1�,�4 iQ : �,t —' l`` 0 s� 4,,,A4,,o,t la,0
4.Date well(s)abandoned: 9 Io�-J (9-0,2 3
'Rt,,g Rxob..
5a.Well location: '
{
nay rnLrc•-• • s o ry
Facili /Owner Name Facility ID#(if applicable) 8 'ertilic tion•��
11Sa Grown Ri. Gels.. ^OIL NC 2R327 -A'�r�r��ei i— ' 2$ 4 3
Physical Address,City,and Zip ®® Signa.re o f r !- ntracto .r Well Owner ` Date
By signing.this form, I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 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 lat/long is sufficient) 9.Site diagram or additional well details:
3�,79-79 zoo N 7 9 (-i0 �i q i 7/' 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 SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-watersupply 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#: Af abandonment to the following:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: I-)q (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:
i
q .
6d.Water level below ground surface: `T_1 (ft.) Division of Water Resources,jUnderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
q
6e.Outer casing length(if known): 1 y 9 (ft.) 10c.For Water Supply&Iniectiion 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 where
6f.Inner casing/tubing length(if known)': "0 l (ft.) abandoned.
6g.Screen length(if known): Al! (ft.)
-ihr'
a�-st Fr oEr�my�i.,GW-30:^* ` North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016