Columbus_Well Abandonment_20231228 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 1
WELL ABANDONMENT DETAILS
1.Well C nJractor 1 151 at �5
-1 1 7e.Number of
inwells being abandoned
For tnultlple injection ar non-waterl supply wells ONLY with the same
Well ContractorNeme(or well owner personally abandoning well on his/her property) constnrction/abandonnient,you can svbnrtt onefornt.
7b.Approximate volume of water remaining in well(s): (gal•)
NC Well Conte for Ce fiuston Number
(� /���/G JnL ;4 FOR WATER SUPPLY WELLS ONLY: / A
Company Name i� 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well pernrits(t.e.Cormry,State,variance,Injection,etc.)ifknoN'n 7d.Amount of disinfectant used:
3.Well use(check well use): 7c.Sealing materials used(check all thatoDryClay
ly):
Water Supply Well: ❑Neat Cemen(Trroul" "' '" Bentonite Chips or Pellets
❑Agricultural ❑Munici al/Public ► t V
p pP y(single) ❑Sand Cement(s`to 7.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su 1 ❑Concrete Grout D E cl Q 20�� ❑ Drill Cuttings •"
❑Industrial/Commercial OResidential Water Supply(shared) 6a O ❑ (,ravel
❑ Specialty Grout
❑Irri ation ❑Bentoniteamy -4en tprCC866lfV ub�Other(explain under 7g)
Non-Water Supply Well: DW01300
❑Monitoring ❑Recovery 7L For each`material selected above,:provide amount of materials used:
Injection Well: dwater Remediation
U
❑Aquifer Recharge roun❑Aquifer Storage and Recovery ❑Salinity Barrier rD [7y3`?"6 �
❑Stormwater Drainage
❑Aquifer Test I
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description/of the;ahand: nt procedure: '/- r�
❑Geothermal(Closed Loop) ❑Tracer �u,,�ap' 0�l(%r� 3G �0`� �""t T 21"i
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: �f
Weir`-
So.Well loco
1 t✓�. 8.Certify tion:
Facility/OwnerComere I Facility IDN(if applicable) �
v t Signature of Certified Well Contractor or Well Owner Date
Physic dre s,City,and Zip
®fum�us 1 By signing this form, 1 hereby cerlifj,that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 1 SA 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
(if well field,one lat/long is sufficient) You may use the back of this page to provide additional well site details or well
N b qL 7-8 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well eanslntcrion reeord(s)if
available. For multiple injection or non water supply
wells ONLY with the same constructionlabandomnent,you can submit one form. 10s. For All Wells: Submit this form within 30 days of completion of well
� ff abandonment to the following:
6a.Well ID# W
Division of Water Resources,Information Processing Unit,
1 r 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: ' " (ft.)
10b.For lniection Wells: In addition to sending the form tothe address in 10a
above,also submit one copy of this:form within 30 days of completion of well
6c.Borehole diameter (in.) abandonment to the following: i
• Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: �' (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
n loc.For Water Suaaly&lniection Wells
aLU u2- : In addition to sending the form to
6e.Outer casing length(if known): v (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.)
i
6g.Screen length(if known):
VA, (ft.) i
North Carolina Department of Environment and Natural Resources-Division of Water Re'ources Revised August 2013
Form GW-30
it