Columbus_Well Abandonment_20231228 (19)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS;
1.Well Contractor Information
A.) '4s�kee For
Number of wells being abandoned
):
66vI ' ' For multiple injection ar non-water) supply wells ONLY with the snore
Well Contractor Name(or well owner personally abandoning well on his/her property) constructton/abandonnient,you can submit one fors:.
3339 7b.Approximate volume of water remaining in well(s):
NC Well Contractor Ceertiirtifil4T,Gcation er-A 5S�t FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name /� n
2.Well Construction Permit t/: 1 v I
List all applicable well pernrits(i.e.Coun%State,Variance,injection,etc..)ifknoHm 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that apply):
Water Supply Well: ❑Neat Cemerlt•Gro�r; �Bentonite Chips or Pellets
❑Agricultural ❑MunicipaWublic Dry Clay
(single) ❑ Sand Cement 7rbut�s� 3t�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SupplyDrill Cuttings
OResidential Water Supply(shared) ❑Concrete Grout Q 20��
❑Industrial/Commercial ❑ Specialty Grou E. O ❑ Gravel
❑Irri lion ❑Bentoni ,. ❑ Other(explain under 7g)
Non-Water Supply Well: �.t2n Prac"Qt v LIAR
��ve,
❑Monitoring ❑Recovery f'e 7f.For each materia s e -provide amount of materials used:
Injection Well:
[]Aquifer Recharge �rroundwater Remediation 31(]
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology oSubsidence Control 7g.Provide a brief description of the.abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �ai
lm c3�'°6'e 4d� !_ C4i J G�ou ti� Zit
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) p,)& / It� w;4 ��/v� r ` `L _`' ,-
4.Date well(s)abandoned: f�/ ,/'t l
Sa.Well loc lion: �S r G� /1k7f 6 J�1 e— CAA
8.Certif ation:
I
Facility/Owner sme Fa 'IityIDil tfapp06, Well Aluk ' 0,
licable)
Sig�raturc off rtified ell Contractor or Well Owner Dale
Physical Address,City,and Zip .
/o/ �b uf EG-Ea I q By signing this form, I hereby certify that the wells) was(were)abandoned in
ti (—(— Parcel Identification No.(PIN) accordance with 1 SA 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
(if well Held,one lat/long is sufficient) p p You may use the back of this page to provide additional well site details or well
3 Np abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well eautruction record(sJ if available. For multiple injection or non-eater supply
wells ONLY with the sane consrruction/obandoninent,you can.submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDii:
abandonment to the following:
5 ~I -
Division of Water Resources,Information Processing Unit,
r t 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: 'J (ft.)
Job.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: U�9`n 0 vl''(in.) abandonment to the following:
l Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �l (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
lOc.For Water Suaaly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): �� �� ft.) the address(es) above, also subm,t,one copy of this form within 30 days of
completion of well abandonment toy the county health department of the county
where abandoned.
6L Inner casing/tubing length(if known):_ —00
6g.Screen length(if known):
(JyVkL0 LL11 (ft.)
."' .Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013