Columbus_Well Abandonment_20231228 (15)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Co rActor Information: WELL ABANDONMENT DETAIL
(e'p- 7a.Number ofwells being abandoned:
For rnulaple injection ar non-wares supply wells ONLY with the same
Well Contractor Name(Orwell owner personally abandoning well on his/her property) c......ctian'abandonntent,you can submit one form.
53 1 7b.Approximate volume of wafer remaining in well(s):
NC Well Contractor Certificad Number
FOR WATER SUPPLY WELLS ONLY:
Compan N me 7c.Type of disinfectant used:
2.Well Construction Permit M
List all applicable well permits(i.e.Cortnty,Stare,Variance,injection,etc.)iitknown 7d.Amount of disinfectant used:
3.Well use(check well use): 7e.Sealing materials used(checkall,that ):
Water Supply Well O Neat Cement Grout entonite Chips or Pellets
❑Agricultural ❑Municipal/Public ❑D Clay
Supply) ( • g ) ❑Sand Cement.Groute,. .. Dry y
❑Geothermal(Heating/CoolingSu 1 OResidential Water Supply(single) b. ' 1 F '° ❑ Drill Cuttings
OResidential Water Supply(shared) ❑Concrete Grout.1 L�;
❑Industrial/Commercial ❑ Specialty Grout c1 ❑ Gravel
❑Irri ation ❑Benlonile Slurry DEC 2 8 2O23 ❑ Other(explain under 7g)
Non-Water Supply Well:
❑Monitoring ORecovery 7E For each)t5'eri2Fia1►s'tTe2te�d�B6Gt:�t �d�3amount of materials used:
Injection Well: undwater Remediation 0 q06, �y CAM
OAquifer Recharge ro
OAquifer Storage and Recovery 6.1inity Barrier
❑Aquifer Test ❑Stormwater Drainage G 9
❑Experimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop)
❑Tracer �`�GL DILYt �G�4 oJJ1G6 �vur, z"
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) DUG W `u 'e
�Pe
4.Date well(s)abandoned: U
59.Well to tion:
. t
S.Certif tion:
Facility/Owner Na le F cility ID# rfapplicable)
11
LN Siana use of Certified Well ontractor or Well Owner Date
Physical dr s,City,and Zip
�s, �bt) LE `� By signing this form, I hereby certify that the well(s)was(were)abandoned in
P stet Identification No.(PIN) accordance with 1 SA NCAC OZC.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:
(ifwcll field,one IatAong is sufficient) i You may use the back of this page to provide additional well site details or well
1a !a U � t j� t N g'I f W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL( BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)If avotlabl For ntrtltrpie injection or non water supply
wells ONLY with the same Onstruction/abandomnent,you can subinit one form• 10a. For All Wells: Submit this form within 30 days of completion of well
r
A�` abandonment to the following:
69.Well IDiI:
Division of Water Resources,Information Processing Unit,
/ 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: ,I O (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
f /y,'�riVLLy� above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter. ` (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
UV"L6k xvh 10c. For Water Sunaly&Injection Wells: In addition tosending the form to
6e.Outer casing length(if known): (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
ate— where abandoned.
6E Inner casing/tubing length(if known): (ft.)
O� �� �
6g.Screen length(if known): (if)
Form GW-30
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

WELL ABANDOPMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS
1,Well Contractor InforpW ton: j
9 7e.Number of wells being abandoned:
with the same
For mulcle injection jection or non-water supply wells ONLY
t P
Well Contractor Name(or well owner personally abandoning well on his/her property) eonsintction/abandonntent,you tan s•ubnift one jornr.
3C� 7b.Approximate volume of water remaining in well(s): _(gal•)
NC Well Contractor Certification
NtlmL beA
5�
FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name W-
List2.Well Construction Permit#:all applicable well permits(f.e.Cottnry,Sate,Variance,injection,etc.)ijknoN•n
7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check Oil that ap ly):
Water Supply Well: ❑Neat Cement Gtovt"" Bentonite Chips or Mies
❑Agricultural OMunicipal/P.ublic -U ! Clay
❑Geothermal(Heating/Cooling Supply) DResidential Water Supplysin le ❑ Concrete Grout D� _ D rill Cuttings
❑industrial/Commercial OResidential Water Supply(shared) L 2 8 2023 D Gravel
❑ Specialty Grout
❑Irri lion ❑Bentonite Sffikr fMaUan Pri ❑ Other(explain under 7g)
Non-Water Supply Well: DWO' "upk
❑Monitoring ORecovery 7f.For each material selected a `ov",provide amount or materials used:
In ection Well:
J 1G t?yrr
DAquifer Recharge oundwater Remediation r d 6 �i
DAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment�procedure:
❑Geothermal(Closed Loop) OTracer r Ge- gI,trW 3Vr
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �.Vt_��� t�/t/� ,L y r d
4.Date well(s)abandoned:
Sa.Well location:
a l �� C��V iG�cl�#•0 P(�� S.Certi lion: ,
Facility/Owner Name Facility IDN qf applicable)
f r py Lfi
l �y�l ' �l l/'4 L'
11 I\ �i ure of Certi Well Con ctor or Well Owner Date
Ply al{�ddresso Ctry,and Zip
(�� By signing this jorm, /herebycert�,that the well(s) was(were)abandoned in
1�tl l 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: 9.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
a I l U J 2 f W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED SUBMITTAL INSTRUCTIONS
h well cottslntcrion record(sJ if avoilobl�. For mnlriple injection or non-water supply
AttacAttach
ONLY with the sat cons7rttcrion/abandomnent.you can submit one jorm. 10a. For All Wells: Submit this form within 30 days of completion of well
wells
abandonment to the following: 1
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
2�2 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: Jl (ft.)
IOb.For Iniection Wells: In addition to sending the form to the address in 10a
t f}� � above,also submit one copy of this'form within 30 days of completion of well
6c.Borehole diameter: V ' ' (in.) abandonment to the following:
/ Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water SUpA1y&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): V EE tit.) 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):f/bVkA-�m—(ft•)
t t.t (tt.)
6g.Screen length(if known): �
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Res l urces Revised August 2013
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