Columbus_Well Abandonment_20231228

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS
1•We ontraclnor_Info mation
!1 C'Cb,, 7a.Number of wells being abandoned:
Ur For mulaple injection ar non-waler� 'supply wells- ONLY with the same
Well Contract Name(or we owner personally well on his/her property) eonstntction'abandonment,you can svbritit one farm.
7b.Approximate volume of wafer remaining in well(s): (gal.)
NC Well Contractor Certification Number
G FOR WATER SUPPLY WELLS ONLY:
��►a- � A55 0�
7c.Type of disinfectant used:
Company Name
2.Well Construction Permit#: A*
b List all applicale well pern»is(i.e.County,Sure,Variance,injection,etc.)ijlmawn 7d.Amount of disinfectant used:
3.Well use(check well use): ):y
7e.Sealing materials used(check all that a
Water Supply Well: ❑Neat Ceme ''•� 1• entonite Chips or Pellets
pAgricultural ❑Municipal/Public i� Dry Clay
❑ Sand Cement ro
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Concrete Grout Q 20��
❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) DEC U ❑ Gravel
Specialty Grout
❑Irri ation ❑Bentonitk9wya en PrCc9b utlse❑ Other(explain under 7g)
Non-Water Supply Well: DWQi'BOG
❑Monitoring ❑Recovery 7f.For each material sFlected above,provide amount of materials used:
Injection Well: G_rfi
ioundwater Remediation 3e d
❑Aquifer Recharge GtJ� G✓
❑Aquifer Storage and Recovery ❑Salinity Barrier /� 31,V1 J fide- �4)
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of they aba ndonmfnt procedure:
❑Geothermal(Closed Loop) ❑Tracer �, t t� Dttr/e✓ /(�4 cJ d//I C- C%hgt t/�'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ttt��� / / I` ew s�
I.Z�G� Z3 �o ;i�
E5?
wiy-
4.Dale well(s)abandoned:
So.Well location:
2 � ct
A4B.Cer fication: J
Facility IDit(if applicable) �
Flity/Owner Name i,Z- G�f�//J23
Si azure of Certified Well Contractor or Well Owner Dale
Physic 1 lddress,City,and ZiPBy signing this form, /hereby certifythat the well(s)was(vere)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 field,one Iallong is sufficient) You may use the back of this page to provide additional well site details or well
t W abandonment details. You may also attach additional pages ifaecessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cotulyction records)f available. For ntitlttple injection or non water supply
welif ONLY with the same constructionlaba�nmetil,you can submit one form• 10a. For All Wells: Submit this form within 30 days of completion of well
p 1,/� abandonment to the following:
6a.Well ID#: v r V K
Division of Water Resources,Information Processing Unit,
�-� ( 1617 Mail Service Center,Raleigh,NC.27699.1617
fib.Total well depth:
i (ft.)
106.For Infection Wells: In addition to sending the form to the address in a
above,also submit one copy of this!form within 30 days of completion of well
6c.Borehole diameter• U' ""�U (in.) abandonment to the following:
f Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 1' (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
I0c.For Wafer Suaaly&Injection Wells: In addition to sending the form to
fie.Outer casing length(if known):
J{ti�h b tv{ti- (ft.) the address(es) above, also submit j one copy of this form within 30 days of
completion of well abandonment to?the county health department of the county
where abandoned.
611 Inner casing/tubing length(if known): _—(ft.)
�l wl��owvt.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013