Rowan_Well Abandonment_20231204

WELL ABA DONML+'NT RECORD IFor Internal Use ONLY:
n
1.Well
Contractor Information: WELL ABANDONMENT DETAILS'
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor 14me(or well ovmer personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
1�y C wells abandoned:
NC Well ContractorrtificationNumber 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan Well & P u mp,C 1 N C FOR WATER SUPPLY WELLS ONLY:
Company Name nulated chlorine
7c.Type of disinfectant used: gr,.a
2.Well Construction Permit#:�88 e C�7 01 — —1,
List all applicable well construction permits(i e.LTC,Coung,,State,Variance,etc.)if/mown
7d.Amount of disinfectant used: OZ
3.Well use(check well use):
Water Supply Well: - 7e.Sealing materials used(check all that apply:
❑Agricultural ❑MunicipahTublic ❑Neat Cement Grout IWBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) C�idential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hiigation ❑ Specialty Grout _ ❑_Gravel
Non-Water Supply Well: ❑ Bentonite Slurry %-'1—..;: -�i ,r ;Other(explain under 7g)
❑Monitoring ❑Recovery f
Injection Well: 7f.For each material selected! lidve2M3ide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage qS
❑Experimental Technology ❑Subsidence Control J
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /� nnww
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ft V—11 u S eX['601otf es ig2I Ql►�
4.Date welI(s)abandoned: f0 leen� n 1 ' . yd m�e& kn�n✓V(e. ,
Sa.Well location: ,
Facility/Owner Name Facility ID#(if applicable) 8.Certifica'On:
Physical Address,City,and Zip Si to of Certified Contr for o ell Owner Date
1 ItllAIfil(1 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 beers provided to the well owner.
5b.Latitude and longitude in-degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
�� 56 N �n .C W You may use the back of this page itoprovide additional well site details or well
J �, 7 abandonment details. You may also.attach additional pages if necessary. '
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
. IOa. For All Wells: Submit this form within 30 days of completion-of well
6a.Well ID#: 3( abandonment to the following:
cyr Division of Water Resources,Information Processing Unit,
6b.Total well depth 8 (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: I A- (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: ')e (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): k (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 completion
of well abandonment to the co health health department of the county where
6f.Inner casing/tubing length(if known): k (ft.) abandoned
i
6g.Screen length(if known): X (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016