Columbus_Well Abandonment_20231228 (12)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form Can be used for single or multiple wells
WELL ABANDONMENT DETAIL
1.Well Conl[actor Informal'() 9,
(/�-- r;l, 7e.Number of wells being abandoned: r
Fa mult/ple injection or non-wares supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) constn(ction/abandonment,you can submit of a form.
3 W 7b.Approximate volume of water remaining in well(s): (gal•)
NC Well Contractor Certification Number
M ` ►1111 1FOR WATER SUPPLY WELLS ONLY:
j 7c.Type of disinfectant used:
Company Name `
2.Well Construction Permit#: fJ1 r/
List o/1 applicable well pernriu(i.e.Corrnry,Sure,Variance,lnjecrlon,arc.)iflmown
7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that )'
Water Supply Well: ❑Neat Cement Grout Sentonite Chips or Pellets
❑Agricultural ❑Municipal/public ,.,
1 ❑Residential Water Supply(single) ❑Sand Cement Gr +C '�—J VIE Clay
❑Geothermal(Heating/Cooling Supply) ❑Concrete Grout ``O�••r. I Cuttings
❑Industrial/Commercial Residential Water Supply(shared) DECGravel
❑ Specialty Grout C 2.Q ,202
202�
❑lrri tion ❑Bentonite Slurry v Other(explain under 7g)
Water Supply Well: 411ftfR 'tt'D Pft:� �ll
❑Recovery 7f.For each material selec >bv omount of materiels used:
$�On�ftoring
Ll o%
❑Aquifer Recharge '❑Groundwater Remediation `
❑Salini Barrier ✓ l/� n
[]Aquifer Storage and Recovery !1 1 kc� 3'g � t l otl(dam r j79
❑Aquifer Test ❑Stormwater Drainage ,
❑Subsidence Control 7 Pr vide a brief description of the abandonment procedure:
❑Experimental Technology g r_ (, �®
❑Geothermal(Closed Loop) ❑Tracer 000 3I$ 6 `r'Bl %' �`0
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) IV �V` 'lM1'tU) 1[lt � tiN 16C f
Z 2i3 T. 1,W4 �d ,e b s 6�
4.Date well(s)abandoned:
52.Well location:
S.Cc r I tcation:
Fttac��ility/Owner Name /� Facilitt�y,I��Di1(ifap licable) ,� >�..q z
`t I S. �C �Uw�l k�r�i/', 1WAI" /l��/ Li /+"L' [ L/�(
_ nature of Certified Well Contractor or Well Owner Dale
Physical ddress,O ,and ZIP
By signing this form, 1 herebycertifythat the wells)was(were)abandoned in
rQ UALE�
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County 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: 9.Site diagram or additional well details:
(ifwell 5eld,one lat/long is sufficient) 0 t You may use the back of this page to provide additional well site details or well
p
-3'f'i R lq,q N 0 L12, ZDl W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For niumple injection or non-eater supply
wells ONLY with the sain consinrction/abandonrnent,yott can subtnit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
I - to.
Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
G 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: I—quo
lOb.For Infection Wells: In addition to sending the form lathe address in]Oa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: UwIC.AD " (in.) abandonment to the following:
I
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Cc I nter,Raleigh,NC 27699.1636
I � � lOc.For Water Suoaly&Infection Wells: In addition to sending the form to
(J
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 to,the county health department of the county
where abandoned.
6f.Inner casing/tubing length(if known):•__ M-)
uh��pttiti (ft.)
6g.Screen length(if known):
f
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
Fora,GW-30
I