Columbus_Well Abandonment_20231228 (13)

WELD ABANDONMENT RECORD =WELkBAND
se ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
ONMENT DETAILS
5 79.Number of wells being abandoned:,
For multiple injection or non-water -Tip—ply wells ONLY with the same
Well Contractor N2eme(or well owner personally abandoning well on his/her property)
consvructton/abandonment,ya+/can submit one fn
3 J3(j`p 7b.Approximate volume of water remaininLng in well(s):
(gel•)
NC Well C 'acr'entifi tion�umb r 1 A 6C h'
]TT�J r,1y J VLr FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name J�
2.Well Construction Permit#: I �►
Lis/all opplicable well perm its(i.e.Cw+nry,state,variance,Injection,arc.)if/moNm
7d.Amount of disinfectant used:
3.Well use(check well use): 7e.Sealing materials used(check all RClay
Water SupplY Well: ❑Neat Cement Gr�> ^:„ ntonite Chips or Pellets
❑Agricultural ❑Municipal/Public ❑ Sand Cement Grou❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)Resi 11 Cuttings
dential Water Supply(shared) 0 Concrete Grout
❑]ndustrial/Commercial ❑ Specialty Grout IE � 8 20�3❑ Gravel
❑Irri lion ❑Bentonite Slrff•W:te tt ►'fcc ❑ Other(explain under 7g)
Non-Water Supply Well: DWcow
ba
❑Monitoring ❑Recovery Tr.For each material s acted above, rovide amount of materials used:
Injection Well: �tit
��l
❑Aquifer Recharge Wroundwater Remediation❑Aquifer Storage and Recovery ❑Salinity Barrier 11 0
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonmept procedure:
❑Geothermal(Closed Loop) ❑Tracer �U f Le. Qt KK'e,,l 3 g U
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) .Ztl w— WeI
2 b Z3 �;`, �( ' �- Gate ftl�j
4.Date wells)abandoned: �. � if 1
Sa.Well locat'on:
8.Certifi tion:
F cility 1Dp if applicable)
Facili / nerNa e �� V�7rt r �1)1 �`
Si of Ce ed Well Contractor or Well Owner Dale
phyg cal Address,C'ty,and Z+p
X; '2i0 By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
y 111 octal ldenrification 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: y Site diagram or additional well details:
(if well field,one Iat/long is sufficient) p l Z You may use the back of this page to provide additional well site details or well
31 G0 1qt K N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cotutevction r,cord(s)if available. For nminple injection or non—water supply
welts ONLY with the same construction/abandomnent,you can.submit one form. 10a. For All Webs: Submit this form within 30 days of completion of well
6s.Well ID#:
A5d� abandonment to the following:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: (ft.)
106.For Iniection Wells: In addition to sending the form to the address in IOa
i above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: n� LI/ (sn.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:
�/ 1636 Mail Service Center,Raleigh,NC 27699.1636
(ft.)
IOc. For Water Suoaly& Iniection Wells: In addition to sending the form to
�� (ft.) the address(es) above, also submit'one copy of this forth within 30 days of
6e.Outer casing length(if known):
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):
V � (ft.)
North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
Form GW-30
I

"Co" or Internal use ONLY:
WELL AEAN )ONM[ENT
This form can be used for single or multiple wells
WELL ABANDONMENT
I.Well Contractor Information: DETAILS
f s rJ 79.Number of wells being abandoned.
d:
For• multiple injection or non-water supply wells ONLY with the some
Well Contractors Name(or well owner personally abandoning well on his/her property) construcaon1abondonment,you can su6nill'6ejornr.
3 J 7b.Approximate volume of wafer remaining in well(s): (gel•)
NC Well Contra or Ce cati n Nu ber
l A G,
P�t L !L l S p FOR WATER SUPPLY WELLS ONLY
91""11
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List oil applicable well permits(i.e.Calm%Stare,variance,injection,etc.)ifknown 7d.Amount of disinfectant used �`y
3.Well use(check well use):
7e.Sealing materials used(check all thaRmi*11
Water Supply Well ❑Neat Cement Qnopt._„ tonne Chips or Pellets
❑Agricultural ❑Municipal/Public tom'�! Clay
pp y( • g ) ❑ Sand Cement Gfiluil=t�� L❑Geothermal(Heating/Cooling Supply) ❑Residential Water Su 1 sin le Cuttings
idential Water Supply(shared) ❑Concrete Grout
ORes
❑industrial/Commercial ❑ Specialty Grout DEC 2 8 2023 ❑ Gravel
❑ n ate ❑ Other(explain under 7g)
Non-Water Supply Well: ❑Bentonite��r�ft :fCtt r�fCt
❑Recovery provide amount of materials used:
❑Monitoring 7f.For each material s�I�t�li�o 5,p
Injection Well: Elinity
— w4
❑Aquifer Recharge undwater Remediation Z G�S,❑Aquifer Storage acid Recovery Barrier �S gVtgl
pAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ;l
❑Geothermal(Closed Loop) ❑Tracer 5 J/ (2 D Ip/'P.l� 31ey (/►t S d�tGl"-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
Sa.W 11-�ation:
�•f [_) �Ui��' ( 8.Certion:Facility/Ow r NaFaciM ID, � applicable)� oCv , � , ,
/ Sin re ofCerts ed Well Consractoror Well Owner Date
Phyr]Al dress,
U-S dress,Ci ,and Zip 5 a `
/L�' trj' C� By signing this joint, I herehy certh,that the wells) was(were)abandoned in
Parcel Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
County and that a copy ojthis 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:
(iif el ��,one lavlonng-is sut5cient) a� 9 � � You may use the back of this page to provide additional well site details or well
qt if>I Q N ) , W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well corrstrucrion record(s)Javarlable. For nrulnple injection or non-water supply 10a. For All Wei
Submit this form within 30 days of completion of well
welts ONLY with the some c nsrructlan/. m n ,Yr�cgn•rubrnirgnefpn abandonment to the following:
69.Well ID#: FLT4
Division of Water Resources,Information Processing Unit,
I j 1617 Mail Service Center,Raleigh,NC.27699.1617
66.Total well depth: L�t / (ft.)
lob.For Infection Wells: In addition to sending the form to the address in 103
above,also submit one copy of this form within 30 days ofcompletion of well
6c.Borehole diameter: v V (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: V (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
lOc. For Water SO y&Infection Wells: In addition to sending 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
where abandoned.
6f.Inner casing/tubing length(if known): `— (ft.)
(ft.)
6g.Screen length(if known):
Fomi OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
1