Columbus_Well Abandonment_20231228 (24)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells i
tractor Information: WELL ABANDONMENT DETAILSI C•
1,Well Cow —
(/� fr 7a.Number of wells being abandoned:
$C et// 1 wells ONLY with the sonic
For tnulaple infection or non-warer� svpp y
Well Contractor Name(or well owner personally abandoning well on}is/her property) constrttctionlabandonnnent,you can submit one form.
7b.Approximate volume of water remaining in well(s):
NC Well Contractor Certification Num A
FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name J�
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)ijhnoum 7d.Amount of disinfectant used:
3.Well use(check well use): 7e•Sealing materials used(check all that a_ ):
Water Supply Well: ❑Neat Cement Grout entonite Chips or Pellets
❑Agricultural ❑Municipal/Public ,�•-� �. ❑Dry Clay ,
❑Sand Cemni. �
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) E ❑ Drill Cuttings
OResidential Water Supply(shared) ❑Concrete Ciro
❑Industrial/Commercial ❑ Specialty GrouI 2 g 2023 ❑Gravel
❑Irri ation ❑Bentonite Slurry ❑ Other(explain under 7g)
Non-Water Supply Well: "en r?rCC',ltl9I�s W1111
❑Monitoring ❑Recovery 7f.For eac materials 9 S�,ve,provide amount of materials used:
Injection Well: 3l O G/
❑Aquifer Recharge roundwater Remediation V
[]Aquifer Storage and Recovery "`vvv❑������"Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provides brief description of the abandonme t procedure:
❑Geothermal(Closed Loop) ❑Tracer 'jr,�/�LGt PVa1d 1�ti C/4
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) UL '�/el
It�/l 'v/
4.Date well(s)abandoned:
53.Well 1 tion:
-'•(-� C.l�lh) G•S � (,t��1 �1,o-ttr�y,y -('fie..._ �ocrs...
q v
rV1LQ t-,Yt 8.Certift ton:
Facility/Ow er Na a Facility IDH(if applicable) ( z/ 9
1 "v �I" V�t �� G� �Q� 9 Si$ ure of
ed Well Contractor or Well Owner Date
Physical ddI ,City,and Zip �t L�� t
Go�u�,�,, 11 By signing this form, /hereby cer1�,that the well(s)was(lucre)abandoned in
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:
(if well Geld,one IaVlong is sufficient) o ' You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)of available. For muilipl,injection or non water supply
wells ONLYwith the$on a cons•Irttction/abandomnent,you can subunit one form. Ion. For All Wells: Submit this form within 30 days of completion of well
!I abandonment to the following:
6a.Well ID#: " nK, V E V
LL Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: (ft.)
IOb.For Iniection Wells: In addition to sending the form lothe address in l0a
�(� above,also submit one copy of this'form within 30 days of completion of well
6c.Borehole diameter U�v-���n(in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface. �'3 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
L)n kVID W n loc.For Water Suoaly&Iniection Wells: In addition to sending the form to
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.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
onkn U wn (ft.)
1
Form OW-30 North Carolina Department of Environment and Natural Resources_Division of Water Resources Revised August 2013
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