Columbus_Well Abandonment_20231228 (25)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Well Con
actor Information:
WELL ABANDONMENT DETAIL
A �Isrk� v For Number ofwells being abandoned:
For snulaple injectton .or non-water, supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) constructionlabandonment,you can submit one form.
�j 13 7b.Approximate volume of water remaining in well(s): �a (gsl.)
NC Well Contractor Cem'Sgauon Number S
� l7(✓ FOR WATER SUPPLY WELLS ONLY:
t� G�
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit M
List all applicable well permits(i.e.County,Stare,Variance,Injection,ere.)ijknown
7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that hD
Water Supply Well: ❑Neat Cement Grouter nite Chips or Pellets
[]Agricultural ❑Municipal/Public �Z U L $ lay
pp y(single) ❑ Sand Cement Grout
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Sts 1Drill Cuttings
OResidential Water Supply(shared) ❑Concrete Grout DEC 2 8 20
❑industrial/Commercial ❑ Specialty Grout �Grhavel
❑Irri lion ❑Bentonite Slurry 1tlkKff►,4cn Pr %(explain under 7g)
Non-Water Supply Well: DWQ%SIG
❑Monitoring ❑Recovery 7f.For each material selected above;provide amount of materials used:
Injection Well; '
❑Aquifer Recharge o oundwater Remediation `3, � q or3, W L' J
❑Aquifer Storage and Recovery ❑ -2,Salinity Barrier '�1 sr 31 a bQntt�t
❑Aquifer Test ❑Stormwater Drainage 7
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonm/ent proceduree,:,
❑Geothermal(Closed Loop) ❑Tracer S1111- optre L-�f "�►`i�ht/�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) , r UC v y )I tG�lY j 'oV f6 A,,c z 64y
l z� z3 v�e�i� (v� �/ - s -&s
4.Date wells)abandoned: ,
2Certiflic
0(0
Sa.Well cation: �j
1 e✓1/19(� A"r3 Facility/Owner Namflit�1`N ifapplicable)� V N167 ac gned Well ontractor or Well Owner Date
Physical Addre ,City,and Zip �/
I�m J 1,0 GA
1 By signing this form,/herebyCo certify that the well(s) was(were)abandoned in
[[ Parcel Identification No.(PIN) accordance with 15.4 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 field,oneJat/long is sufficient) b 1 You may use the back of this page to-provide additional well site details or well
3 q o /q I g t� N L� / W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well eo»strucaon record(s)if available. For multiple injection or non-water ater supply
wells ONLY with the son le construction/abandontnent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well IDN: Un
l Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: ' (ft.)
lOb.For Infection 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: �Rt) — (in.) abandonment to the following:
C t Division of Water Resources,Underground Injection Control Program,
nter,Raleigh,NC 27699.1636
6d.Water level below ground surface: 31 (ft.) 1636 Mail Service Ce
i,
{ 10c. For Water So IV&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): V11krt b Wig (ft•) the address(es) above, also submiti one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
r— where abandoned.
6L Inner casing/tubing length(if known):_—(ft.)
i
i
{
6g.Screen length(it known): Un 6,0 LLB (ft.) i
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
Form OW-30
t