Columbus_Well Abandonment_20231228 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well cqntractor Information
WELL ABANDONMENT DETAILSI
�q -J 7a.Number of wells being abandoned:
6r "11 �it i it Ft�
—_ For multiple injection or non-wafer, .nrpply wells ONLY with the same
Well Contractor Name(Orwell owner personally abandoning well on his/her property) constrrrctiontabandonnient,you can svbnrit one jornr. _f __
-3 3 Il 7b.Approximate volume ofwater remaining in well(s): E/ (gal•)
NC Well Contractor Fertit cation Number
'L 5S
U L FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name
2.Well Construction Permit#l:
List all applicable well pernrits f.e.Corrnry,Stare,Variance,injection,etc.)iflmosrn
7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check sl�&ntConite
Water Supply Well: ❑Neat Cement GRIM, :—^s Chips or Pellets
❑Agricultural ❑Municipal/Public t btL: la❑ Sand Cement Gro t * y
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) DEC 2.8 2023 ❑Gravel
❑ Specialty Grout
❑Irri ation ❑ Bentonite SII1*f9sQUen Pr Uther(explain under 7g)
Non-Water Supply Well: D.tlooa nt of materials used:
❑Monitoring ❑Recovery 7f.For each material selected a ove,'provide amou
Injection Well:
❑Aquifer Recharge oundwater Remediation
❑Aquifer Storage and Recovery Salinity Barrier I V J 1,5 31�t'
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment prof edurc:
❑Geothermal(Closed Loop) ❑Tracer �,. Gq V lFr� 3 r' 't'iIt T7J nl
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �h v/ GV P j
4.Date well(s)abandoned: �—=— �^ ,<
Sa.Well t-740
T;IV&e—
�4'014 8.Certiftr lion:
Facility/Owner Name Facility 1DN(ifapplicable) ✓ 2I �
tod Signature of Certified Well Contractor or Well Owner Dale
rphlL�ddrcss,
City,and Zip
tti . 0�l wt� By signing this jornr, !hereby cerl i That the well(s) was(were)abandoned in
Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0100 Well Construction Standards
County and that a copy ojthis 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,one latilong is sufficient) u �121 Z You may use the back of this page to provide additional well site details or well
N— 0 I / W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)iJavoilable. For multiple injection or non-Haler supply
wells ONLY with the sae constr tctionlabandoninent,you can subtnit one jornr• 10a. For A� 11 Wells: Submit this form within 30 days of completion of well
m
_ r _' abandonment to the following:
6a.Well ID/h i`�/1✓_ yr1 K d`J l� Division of Water Resources,Information Processing Unit,
L 6b.Total well depth 1617 Mail Service Center,Raleigh,NC.27699.1611
: I (ft.)
106.For Infection Wells: In addition to sending the form to the address in 10a
l above,also submit one copy of this-form within 30 days of completion of well
6c.Borehole diameter: " ) nLVA (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface. t (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636 -
r loc.For Water Sunoly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): VI�vv�► (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.
6f.Inner casing/tubing length(if known):. (ft.)
6g.Screen length(if known):
( �3tifw� (ft.)
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Form GW-30