Davie_Well Abandonment_20231215

WELT ABANDONMENT RECORD Fpr internal Use ONLY.
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1, 11'efl Coitractor Intfor mation: WELL ABANDONMENT DETAILS
L e-G 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Wall 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
^ ^ -)_ w wells abandoned:_ j
NC� ell Contractor Certi6catioh Number 7b..Approximate volume of water remaining in well(s): 'T t0 (gal.)
YADKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used lwonile_
2.'Wcll Construction Permit#: /'��
Lis all applicable tirell catsmrcriat perntits'(i.e.UIC,County,State,parlance,ere.)ifhton•n
7d.Amount of disinfectant used: �Z
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):'
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout( ❑ gentonite Chips or Pellets
• ❑Geothermal(Heating/Cooling Supply) esidenial Water Supply(single) ❑ Sand d Cement Grout.: �
O Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout .( ill C^y.ttings
❑Irrigation.- ❑Specialty Grout 0- Rave
6.4y. _.-PI?Y.. .. ....... .. ..:. :' O.Bentonite Slu' i Cher(explain under 7g)
❑Monitoring ❑Recovery i�r^^^ '. •
Lnir.ctio.!i•ti}'C.Q:.,,. 71 For each mat,erialselel<ft;d� bov�e'=previce,amount of materials used:
.,:
aquifer Recliarge ❑Groundwater Remediation 1"- 7 l..p'd
❑Aquifer Storage and Recovery ❑Salinity Barrier' GV ✓ .S
❑Aquifer Test OStormwater Drainage
❑Experimental-Technology ❑Subsidence Control•❑(ieothe'rriial:(Closcd Loop) ❑Tracer 7g,provide e
a brief description of the abandonmnt procedure:
/ en n /
❑Geothermal;(Heating/Cooling.Retum). ❑Other(explain under7g) �ir[J�1 G!�YJ � WG�( rd�ye� o� �✓ZL/
4.Datc ivell(s)abandoned: ��
5a.NVell.location:
racility/Owner Name Facility ID9(if applicable) 8.Certir, tiou:
Physical Address,City,and Zip QQ� Signature of Certified Well Contractor or Well Owner Date
— (Ale B signing this onn, I herebycertify that t/ie hells ivas were abandoned in
Coubq=;;'_.•_-,�_.. Parcel identification No.(PIN) accordance ivith 1SA NCAC 02C.0100 or 2C:0��,0'11!e/l o+rstr z+ction Standards
..... and that a copy of this record has been providedlb,trre•well;flzvner. '
56'.,L 1ptttde andlongitude in degrees/minutes/seconds or decimal degrees:
(ifyveli:6e}d,-ode lat/longis sufficient)
/� i(�. G C{ 9.Site diagram or additioual.well details- .
3 � l�.' $a� N b D� //�C� ��+0 W You may use the back of this page to provide additional well site details or well
1 abandonment details. You may also attach additional pages ifnecessary.
CONSTR1ICTIONDETAILS OF WELL(Sl BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anaclvirelicousmrctiourecoi•d(.v)'ifavailable. Fa•muhipleirjectionornon-warersupplywells '
ONLI'with the saute constrzrction"abandonntenr,you can submirone form. ,
1. For All )Veils: Submit this form within 30 days of completion of well
6a.Well ID#: �/ abandonment to the following:
Division of Water Resources,Information Processing Unit,
Gb.Total well depth: (ft.),. 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells:. In addition to sending the forrti to the address in 10a
6c.Borehole diameter: (iu.) above,also submit one copy of'this form within 30 days of completion of well
abandonment to the following:
6d.`Vater level below ground surface -(ft.) Division ofWater Resources,'Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) loc.For Water Supply&Infection 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 healt�t.:d'iriartmentaf..ihe county .where
6f.Inncr casin /tubin Icn th if known): abandoned. t.
'':•'':.off - '` .•r; r•s..e :(i�5+. r�. :r,
Gg:_SCrGerj Yeugth(ff known):` (ft.) .. . .
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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