Columbus_Well Abandonment_20231228 (14)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
WELL ABANDONMENT DETAILS
1,Well Contractor ntormation:
Q r t �.S " 79.Number of wells being aba ndon d:
For lnultlple injection or non-water supply wells O1VLy with the same
Well Contractor Name(or well wner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
,�33 1 7b.Approximate volume of water remaining in well(s): t (gal.)
NC Well Co a ctor Ce�ttfica ion N tuber
�'�J � ®�� FOR WATER SUPPLY WELLS ONLY:
7c.Type of disinfectant used:
Company Name
2.Well Construction Permit#:
List all applicable well permils(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used:
3.Well use(check well use): 7e.Sealing materials used(check all that a ).
Water Supply Well: ❑Neat Cement rout,^'- a ,, ntonite Chips or Pellets
❑Agricultural DAqunicipal/public '^^��44��]Ory Clay
❑ Sand Cement ro E.7
❑Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Drill Cuttings
DResidential Water Supply(shared) ❑Concrete Grout DEC 2 U Q 2023
❑Industrial/Commercial ❑ Specialty Grout ❑ Gravel
DIrri lion ❑Bentonite Sl Other(explain under 7g)
Non-Water Supply Well: !�
❑Monitoring []Recovery 7f.For each material sele�cte�a`bo�ve provide amount of materials used:
Injection Well: -3 l) #15S Ut1
❑Aquifer Rechargeundwater Remediation
[]Aquifer Storage and Recovery iii❑ nity Barrier
���---SSali
❑Aquifer Test DStormwater Drainage
❑Experimental Technology DSubsidence Control 7g.Provide a brief��l
of the aban�dopmer��rocedure�
❑Geothermal(Closed Loop) ❑Tracer �y � � tut C,•.��ff��//+t�-i )
OGeothermat(Heating/Cooling Return) ❑Other(explain under.7g) 0 �,�� w 1 L14/ 0
4.Date well(s)abandoned: "�
tUo L4
6U')-- 7AJ�L(
Sa.Well loc �✓ll(-C t� i
S.Certi anion:
n rty I
Faci rty/Ow r Name Facr D f applicable)' C
Blvd,
l
ture of ertified Well Contractor or Well Owner Date
Physic Ad ress�,C,�'; and Zip
�
�/I�/� ort — 2-0 By signing this form, /hereby certifp that the wells)was(were)abandoned in
Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 1C.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: 4.Site diagram or additional well details
(ifwel field,one lat/long is sufficient) D f You may use the back of this page to provide additional well site details or well
N 2 b �--1 r 3 W abandonment details. You may also attach additional pages if necessary.
CO►NSTRUCTION DETAILS OF WELLS BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well eatutnrcrian record(sJ if avaifnble• For yo ltiple injection a non-rater supp y
wells ONLY with the satn construct'on/abandons ens.you can submit one jonrr. ]pa, For All—Wells: Submit this form within 30 days of completion of well
'^ �C_ � abandonment to the following: ,
6s.Well ID#: I J Division of Water Resources,Information Processing Unit,
-),3
j 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: L (ft.)
I0b.For Infection Wells: 1n addition to sending the form to the address in 10a
�o�� (�1� above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter ( (in.)
abandonment to the following:
• t Division of Water Resources,Underground Injection Control Program,
1 'r 1636 Mail Service Center,Raleigh,NC 27699.1636
6d.Water level below ground surface: ( ) ,
loc.For Water Suaaly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): y�DUtN�. (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.
6E Inner casing/tubing length(if known):,_—(ft•)
6g.Screen length(if known):
Revised Au ust 2013
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources 8