Columbus_Well Abandonment_20231228 (20)

WELL ABANDONMENT,RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS!
1•.Well C ntractor Informs iop
�r y ! 5�n� 7a.Number of wells being abandoned!
For tnultlple injection or non-water! supply welts ONLY with the same
Well Contractor Name(or welt owner personally abandoning well on lusher property) cansrnrctionlabandonment,you tan submit one fart".
3�f q 7b.Approximate volume of water remll wining in well(s): (gal•)
NC Well Contractor Certi cats n Nu ber
��//l . _ SS'(J FOR WATER SUPPLY WELLS ONWN
Y
—J l���l 7c.Type of disinfectant used:
Company Name 2.Well Construction Permit 1/:
List all applicable well permits f.e.Cosmry,State,Variance.injection,etc..)if know" 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all thail gi.-Mcinit.
pply Well: ❑Neat Cement Gr ut Chips or Pellets
❑MunicipaWublic i ^•❑Agricultural ❑ Sand Cement Groff Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) l Cuttings
l7Residential Water Supply(shared) ❑Concrete Grout
❑Industrial/Commercial ❑ Specialty Grout DEC 2-8 2023❑ Gravel
❑Irri lion ❑Bentonite SItJIry�� ❑ Other(explain under 7g)
Non-Water Supply Will: tniOf9101l en Prt2C,9"kv
❑Monitoring ❑Recovery 7f For each material selacarovide amount of materials used:
Injection Well: .S
❑Aquifer Recharge groundwater Remediation U V'
❑Aquifer Storage acid Recovery YYY❑���Salinity Barrier f ys 31�It`je ,4-e—
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandon ent procedure: �
❑Geothermal(Closed Loop) ❑Tracer a�t(/C�`31�k�J(Ojti� P� C�u S' dorms"r,/(, —, z
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) t !o `D �/
d v& J
4.Date well(s)abandoned: c!/
52.Well cation:
QTtAtle,- Pon S.Ccrtific ion:
Facility/Ow r Nam Fa slily ID (if applicable) ^
f)
;ig�t re ofCe sfied Well Contractor or Well Owner Date
Physi I dress,CN,and Zip lip — j
Lti J ar V f By signing this form, /hereby certify that the wells) was(were)abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Co my Parcel Identification No.(PIN)
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: y Site diagram or additional well details:
(ifwell fiN
IaVlon is sutficient)N �o �l�� You may use the back of this page to provide additional well site details or well
3 l� y t r W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well coturtvction Word(s)if available. For nsulapi Injection or non water supply
wells ONLY with the same onstntctionlabandonineni you can submit one foray. 10a. For All Wells: Submit this form within 30 days of completion of well
_ abandonment to the following:
69.Well ID#: J
Division of Water Resources,Information Processing Unit,
1 1617 Mail Service Center,Raleigh,NC.27699-1617
6b.Total well depth: ` (ft.)
lOb.For Infection Wells: In addition,to sending the form lathe address in]Oa
uo,�7 above,also submit one copy of this!form within 30 days of completion of well
6c.Borehole diameter• '")lD (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: cl (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
1 n lit h 10c. For Water Suoaly&Tnjection Wclls: In addition to sending the form to
6e.Outer casing length(if known): 01, (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.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
(ft.)
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
Form GW-30

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells r
WELL ABANDONMENT DETAILSi
1•Well Contractor Informatio
7a.Number of wells being abandoned:
For, rnulaple injection or non-wale supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) constrrction/abandonment,you can submit one form. A
3 7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
11 3SUl� FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name
2.,Well Construction Permit
List all applicable we!lpemriu(i.e.Corrnry,State,Variance,injection,arc.)ijknosrn
7d.Amount of disinfectant used:
3.Well use(check well use): 7e.Sealing materials used(check all that Wentonite
):
Water Supply Well: ❑Neat Ceme t.Crrali? _ Chips or Pellets
❑Agricultural ❑Municipal/Public -..•
( • g ) ❑Sand Cement C�r� 1z �� QDry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Concrete Grout Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) 2
❑ Specialty GroutDE L 6t�8 2023 ❑ Gravel
❑Irri lion ❑Bentonite Slurry ❑Other(explain under 7g)
Non-Water Supply Well: N1QOtt�1Ki►uen Proc'mD.t1;U"
❑Monitoring ❑Recovery 7f.For each material�"1yseri)1'$ a Provide amount of materials used:
Injection Well:
groundwater Remediation �t Q
❑Aquifer Recharge GCS, (/✓ ./ ,
❑Aquifer Storage and Recovery ❑Salinity Barrier j; 14,5, 3 h$"A
1 M•I�»I W,' l
(,�vl q3
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment 9pra�e bra:
�}�
❑Geothermal(Closed Loop) OTracerV °:r!w
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) vuv- Z� �� ./l l l G j✓j/J
1) V A � �G
4.Dale well(s)abandoned: c ZI 7 C, ;
5.�1"! jam t /1 . We-/1
8.Certification
Facility/Owner me Facility #(ifapplicable)
6 f1 ' Signatures ertificrl ell Contra tor or well,owner Date
Physical dre City,and Zip
MIZ 19 -G By signing this form, 1 hereby cerliI that the well(s)was(were)abandoned in
llll���� d111 Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y Site diagram or additional well details:
(ifwell 5eld,one lat/long is sufficient) G � l� p You may use the back of this page to provide additional well site details or well
q6 I l �`��� N �'$ "l Z CA/ W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL IS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple Injection or non water supply
wells ONLY with the satne constntctlon/abandontnent,you can submit one fora,. Ion. For All Wells: Submit this form within 30 days of completion of well
9 1 [ p abandonment to the following:
6a.Well ID#: U J 0
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: ` (ft.)
106.For lniection Welts: In addition to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: U� (m.) abandonment to the following:
(� �] Division of Wafer Resources,Underground Injection Control Program,
6d.Water level below ground surface: ` t (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water Suualy&lniection Wells: In addition to sending the form to
6e.Outer casing length(if known): "►' (ft.) the addresses) above, also submit!one copy of this form within 30 days of
the county health department of the county
completion of well abandonment to
where abandoned.
6L Inner casing/tubing length(if known): ,? -(ft.)
6g.Screen length(if known):
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
Form GW-30