Washington_Well Abandonment_20231122

WELL ABANDONMENT RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
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1.Well Contractor.Information: WELL ABANDONMENT DETAILS
Lawrence D. O er f i
PP 7a.Number of well`being abandoned: 9
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple 'injection or non-water supply wells ONLY with the same
construction/abandonment,you can suhm it one form.
3322-A
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
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Regional Probing Services FOR WATER SUPPLY WELLS ONLY:
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Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: 1. !
List all applicable well construction permits(i.e.County,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
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3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 21 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout. ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
EMonitoring ❑Recovery
Iujection Well: 7f.For each material selected above,provide amount of materials;used:_
❑Aquifer Recharge ❑Groundwater Remediation bentonite chips:1.6 Ibs/ft(11-56 Ilis/well) u: =�3r:F ; ergm •,
❑Aquifer Storage and Recovery ❑Salinity Barrier I❑Aquifer Test ❑Storm N O V 2 2n23water Drainage l'
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: `
❑Geothermal(Closed Loop) ❑Tracer I-it•`:i'.•..y',,?
Filled/hydrated from bottom-up. Capped with concrete.DW-1 Dewatered prior to'abandonment.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
DW-1 (35'), MW-1A(9'), MW-2(8.5'), MW73A(10,')MW-4(8')
4.Date well(s)abandoned: 10/19/2023 MW-5(8.5.'), MW-6 (8') MW-7(8'), MW-8(8')
5a.Well location: �.
NCDOT Maintenance Facility
Facility/Owner Name Facility ID#(if applicable) g•Certification:
14193 NC Hwy94, Creswell Lawrence O er,? w 11/6/2023
PPS
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Washington By signing this form, I hereby cei tify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C j6100 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.915830810 76.472257 You may use the back of this page to provide additional well site details or well
/ N W abandonment details. You may also attach additional pages if necessary.'
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONSI
Attach well construction(record(s)if available. For multiple injection or non-water supply i
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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#:
Monitoring Wells-see 7g abandonment to the following: I
Division of Water Quality,Information Processing Unit,
66.Total well depth 7-35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For Iniection Wells: In addition to sending the form to the address in 10a
Well I.D.=2.0 . above,also submit one copy of this'form within 30 days of completion of well
6c.Borehole diameter: in.) abandonment to the following: i
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6d.Water level below ground surface: approX 4 (ft) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit;one copy of this form within 30 days of
completion of well abandonment tothe county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 5 (ft.) i
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water iQuality Revised March 2013