Columbus_Well Abandonment_20231228 (11)

WELL ABANDONMENT RECORD For Internal Use ONLY: ;
This form can be used for single or multiple wells
1.Well Co tractor Informoon: WELL ABANDONMENT DETAILS
�Qft"!SG 7a.Number of wells being abandoned:
ll// N For rnultlple injection or non-water sytpply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) constntction/abandonnrent,you can submit onefornr.
7b.Approximate volume of water remaining in well(s):
NC Well Contractor.Certification Nu m er
J� �-� C e S SU FOR WATER SUPPLY WELLS ONLY:
IVA—
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#l: / v
(i.e.co ,ntyStare,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
List all applicable wellpernrils
3.Well use(check well use): 7e.Sealing materials used(check all thait-a
Water Supply Well: d Neat Cement G ut, <-, �,.„ tonite Chips or Pellets
❑Agricultural ❑Municipal/Public Clay
}PP y( • g ) ❑Sand Cement G o>Sti' ,�i,❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su 1 sin le ❑Concrete Grout Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) DEC 2 8 2023❑Gravel
❑ Specialty Grout
❑Irri lion ❑Bentonite Sl ,. Other(explain under 7g)
Non-Water Supply Well: f S.18D ?ft;C�ow; um
❑v
❑Monitoring ❑Recovery
7E For each material sale t M��rovide amount of materials used:-
Injection Well: /-
❑Aquifer Recharge Ralinity
rroundwater RemediationZ-�
❑Aquifer Storage and Recovery Barrier 't 1 ( s
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description/of the abandonm�eont procedure:
[]Geothermal(Closed Loop)
❑Tracer s aotwd
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) uL ��l/ c• IC"�L,�
Z��I z 3 T'� ;� w t C,�trJ� FK�//y(�! / -
4.Dale well(s)abandoned:
5a.Well cation:
)1 t 1 Gp- � �Gut 8.Certili t' n: \
Facility/Ow er Na Facility.IDN(ifapplicable) p -7 /1
I Nc J ill, �����9 ��4W1 , S
Signature of Certified well Contractor or Well Owner Date
Physical �ddress, s City,and Zip w,G_ I t n
i�� By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
I O 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:(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
/a, F W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well corutruction record(s)if available. For niumple injection or non-Hater supply
wells ONLY with the same constntction/abandonnient,yort can submit one foray l0a. For All Well
Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well IDH: Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
fib.Total well depth: �Z, (ft.)
119b.For lniection Wells: .In addition to sending the form tuthe address in 10a
'9���b above,also submit one copy of this;form within 30 days of completion of well
V
6c.Borehole din meter: (in.) abandonment to the following:
/ Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: of C (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
1 f IOc. For Water Supply— Wells: In addition to sending the form to
6e.Outer casing length(if known): v b�l,(7 Lk (ft•) the address(es) above, also submstl
,� 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.)
Uy'-p`-qG( l (ft.)
6g.Screen length(if known):
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Fomr GW-30