Columbus_Well Abandonment_20231228 (10)

WELL ABANDONMENT RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1•Well Co actor Informatro A I
WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
7 For multiple injection or non-water supply wells ONLY with the same
Well Contractor Name(Orwell owner personally abandoning well on his/her property) comintction/abandonntenr,you can svbntit onejarm.
—3 3 3 q 7b.Approximate volume of water remaining in well(s):
NC Well Contractor CertA'ficati nNrt
` ./1 � , o FOR WATER SUPPLY WELLS ONLY:
�r 7c.Type of disinfectant used:
Company Name
2.Well Construction Permit 4: I V
List all applicable well permits(i.e.Carroty,State,Variance,injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that Q lLLy):
Water Supply Well: ❑Neat Cement Grout Tentonite Chips or Pellets
❑Agricultural ❑Municipal/Public ; .,. Dry Clay
PP y(single) ❑ Sand Cemeno d��L.i / r'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ❑Concrete Grout !T1 Drill Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) ❑Gravel
❑ Specialty Grout D E C 2 8 2023
❑Irri lion ❑Bentonite Slurry ❑ Other(explain under 7g)
Non-Water Supply Well: IfftfillWietl Preis
❑Monitoring ❑Recovery 7(For each material 9lgt`Q) e�VroviBe amount of materials used:
Injection Well: I
❑Aquifer Recharge groundwater Remediation (� 1910) (wt�e✓
v❑Salmi Barrier
❑Aquifer Storage acid Recovery Z I b$
❑Stormwater Drainage
❑Aquifer Test
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Tracer a' 2n�Clt4 G/' ) 2/U ut" z'[
❑Geothermal(Closed Loop) S-Vir 1 �wr' 3 8
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) f
UL e, IO�J�jY I l ,1U � .��/. p��Ur�j p��
4.Date well(s)abandoned: ` Z` r Z'3 "�'C)/) U-�- tV b t t° �G' / t W� b e -' "itis�( alp"
Sa. e1110 tion:
�Z- -
8.
q Facility/Owner N e (�ll a r��I_ Facility IDH(ifapppll cable)
6 n —vow?, �btif�t W h;k6 ) , V��t'l
Sr ure ofCerti tied Well Contractor or Well Owner Date
PlsysicaI ddr ss,City and Zip
���,�yyljytS By signing this jornr, I hereby certify that the well(s)was(were)abandoned in
l((l 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: 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
3 y b LIT' 44'1-- N T7S 0 `L?i abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well conssirmuction record($)Javatiable. For multiple injection or non water supply
wells ONLY with the satn eonstnretion/abandontnent,you can submit one jornr. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following: ;
6a.Well IDN: ' "[
Division of Water Resources,Information Processing Unit,
rn t 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: �"�j' " (ft.)
10b.For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this;form within 30 days of completion of well
6c.Borehole diameter: u�'t�r UI (in.) abandonment to the following: i
i
1 Z t Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: l (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
Wells: In addition to sending the form to
v� ft.) 10c. For Wafer Su of this form within 30 days of
aaly&Infection
6e.Outer casing length(if known): ( the address(es) above, also submit;one copy
completion of well abandonment to;the county health depatlment of the county
where abandoned.
6E Inner casing/tubing length(if known)
L)Wk
6g.Screen length(if known):
hb 1P'11, (ft.)
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
Form GW-30
l