Columbus_Well Abandonment_20231228 (4)

WELL ABANDONMENT RECORD For internal Use ONLY: i
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS
1.Well Contractor Information:
ell SSG '" 7a.Number of wells being abandoned:
For multiple injection or non-wale; supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) constnrctiotVabandonn,ent,you can submit one jornr.
�d 7b`Approximate volume of water remaining in well(s): l/ (gal.)
NC Well Contractor Certification Number
/} a f �-Vrltv_ �'0 C— FOR WATER SUPPLY WELLS ONLY:
Company Name 1� 7c.Type of disinfectant used:
2.Well Construction Permit#: if lmorrn 7d.Amount of disinfectant used:
List o!l applicable well permits(i.e.County.Su arc.re,variance,injection, J
3.Well use(check well use): 7e.Sealing materials used(check all thip.ntonite
):
Water Supply Well: ❑Neat Cement rout•.... ,-.,+ Chips or Pellets
❑Agricultural ❑Municipal/Public ��r� V
( • g ) ❑ Sand Cement rout ry Clay
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) D Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Specialty Grout DEC 2 S 2023 ❑ Gravel
❑Irri ation ❑Bentonite SI 17 Other(explain under 7g)
Non-Water Supply Well: ifPf93.f2ft r�f>rC9fi" 6b�x
c eR W
❑Monitoring ❑Recovery 7E For each material sel bI e, rovide amount of materials used:
Injection Well: /
DAquifer Recharge groundwater Remediation 3,d C Ef/J, (/tI
❑Aquifer Storage and Recovery DSalinity Barrier G� 1l 3)e c�k s
DAquifer Test ❑Stormwaler Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
DGeothermal(Closed Loop) ❑Tracer 3/8t, S". twte �1 (1vu, �H
OGeother nal(Heating/Cooling Return) ❑Other(explain under 7g) n � G 1 r C-4 cl�, 1-,
4.Date well(s)abandoned:
t ZJ z� I �f - Y� e� C V rM�
52.Well 1 cation:
V l lid 4m.-
Facility/OwnerN me Facility DH(ifapplicable) C�/L ��SSign of Certified Well Contractor or Well Owner Date
Physical Addr ss,City,and Zip
10
�t� (� r(I�r�.-�l/ , By signing this form, /hereby certi,that the well(s) was(were)abandoned in
I �J Parcel Identification No.(PIN) accordance with I sA NCAC 01C.0100 or 1C.0100 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,one lat/long is sufficient) ' pr - you may use the back of this page to provide additional well site details or well
U i CJ t l q1 N 0 �fI / W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL/S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)Java,lable. For n,utcan injection a rnon non-water supply
wells ONLY with the same construction/abandonment,ya can
submit one fom. 10a. For All Wells: Submit this form within 30 days of completion of well
r abandonment to the following:
6a.Well ID#: w Division of Water Resources,Information Processing Unit,
v� 1617 Mail Service Center,Raleigh,NC.27699.1617
fib.Total well depth:
`
106.For Infection Wells: In addition to sending the form to the address in 10a
�,� above,also submit one copy of this jorm within 30 days of completion of well
6c.Borebole diameter•��YW AU,Lpl (in.) abandonment to the following:
Q Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: V (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
t loc. For Water Suaaly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): IJULb�h bll�V� (ft•) the address(es) above, also submit done copy of this form within 30 days of
completion of well abandonment to;the county health department of the county
where abandoned.
6L Inner casing/tubing length(if kno/w/n,)::, (ft.)
6g.Screen length(if known): V v ' (ft')
a
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Form GW-30

a
WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Co Zo
nfor tion: WELL ABANDONMENT DETAIL
, 9_r�d 7a.Number of wells being abandoned:
Well Co to erne(or well owner personally abandoning well on his/her property) For multiple injection or non-wafer supply wells ONLY with the same
consrnrcttan'abandonmenr,you can submit fne form.
7b.Approximate volume of water remaining in well(s):
NC Well Co ct r rtificati n Nu bet ��
r i 1� FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: /
2.Well Construction Permit#: /"
List all applicable well permits(i.e.Coun%State,Variance,injection,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all &.ntCnit-
Water Supply Well: o Chi s or Pellets
❑Neat Cement Greut.�,r.,• P❑Agricultural ❑MunicipaUPublic t,.. ,( • g ) ❑ Sand Cement Gi u�,Co r, rylay
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supplysin le ❑Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) DEC 2 8 2023
❑Specialty Grout ❑Gravel
❑Irri ation 1 rrV •p_other(explain under 7 )
Non-Water Supply Well: ❑Bentonite SttultOflTlthtien Prou, 9 llt4Y ( p g
❑Monitoring ❑Recovery 7E For each material selhr ieWNCip provide amount or materials used:
Injection Well: t� �i�. �G
4.1
❑Aquifer Recharge , oundwater Remediation J l r
❑Aquifer Storage and Recovery Salinity Bartier tt( �j�s J t v pjuK a s
❑Aquifer Test ❑Stormwater Drainage v i
❑Subsidence Control 7 rovide a brief description of the bando ment proce ure:
❑Experimental Technology g• v
❑Geothermal(Closed Loop) ❑Tracer - .J o vir J��
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ubtt� r
4.Date well(s)abandoned:
Sa.Well loc ion:
S.Certifica"
Facility/OvrierNfp C
e 4 Fscility�lp#(ifapplicable)
row V W�I1
and Zi Signature ofCertifi Well Contractor or Well Owner Date
Phyr'b[m
l dress, ty, P I
mj W p�� l~ L q By signing this form, !hereby certh)that the we11(s) was(were)abandoned in
Parcel Identification No.(PIN) accordance with I5A 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,o sufficient)
ne lat/long is sucient)
03 L/0l �r% 1 t (V n 17" �¢t You may use the back of this page to provide additional well site details or well
N � u W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well comtruction record(s)y ovotlable. For multiple injection or non water supply
wells ONLY with the scone construcaonlabandoninent,you can submit one form• Ion. For All Wells: Submit this form within 30 days of completion of well
(f abandonment to the following:
6a.Well ID#: v N�V' y ✓
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: ' (ft.)
106.For Infection Wells: In addition to sending the form to the address in IOa
n„lty�b above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: �ltvu (in•) abandonment to the following:
i
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: t 6 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
(.�y lkN LA (ft. 10c.For Water Suaaly&Iniectitin Wells: In addition to sending the form to
the address es above, also submit one copy of this form within 30 days of
6e.Outer casing length(if known): address(es)
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):
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water ReIsources Revised August 2013