Columbus_Well Abandonment_20231228 (16)

REC0
WELL ABANDONMENT 12D Foftemal fNLY:
This form can be used for single or multiple wells Ij
WELL ABAND
1,Well Contractor Information: ONMENT DETAILS
`
7a.Number of well being abandon!d:
For inularle injection or non-water supply wells ONLY with the sonic
Well Contractor
Name(Orwell owner personally abandoning well on his/her property) construction'abandonntent,you can submit one forth.
-33 3 q 7b.Approximate volume of water remaining in well(s):_ (gal.)
NC Well Co v ctor Ce Scott n Nu�'b let n t
_ �-�-� FOR WATER SUPPLY WELLS ONLY:
u"UT
7c.Type of disinfectant used:
Company Name (�
2.Well Construction Permit#: 1
7d.Amount of disinfectant used:
List all applicable well permits(r.e.County,State,variance,injection,etc.)ijl rto"m
3,Well use(check well use):
7e.Sealing materials used(check all that
Water Supply Well: ❑Neat Cement Grr vt t` :v S _ entonite Chips or Pellets
❑Agricultural ❑Municipal/Public s Z L— V Clay
g/ g Supply) pp y( • g ) ❑ Sand Cement Grout
❑Geothermal(Heating/Cooling Coolin Su 1 ❑Residential Water Supply(single) ❑Concrete Grout D ❑ Drill Cuttings
❑Industrial/Commercial OResidential ❑ Specialty Grout `Water Supply(shared) 2 8 20230 Gravel
❑Irri lion ❑Bentonite Slut01'XiNizn r-ar,,c3oz;f19 Q0cr(explain under 7g)
Non-Water Supply Well: [}w0jor
❑Monitoring ❑Recovery 7E For each material select d above,provide amount of materiels used:
Injection Well:
❑Aquifer Recharge 00undwa'ter Remediation (1 I , /t G
❑Aquifer Storage and Recovery ❑Salinity Barrier Q I, 3 g QI )� ��j
OAquifer Test ❑Stormwater Drainage l
❑Experimental Technology ❑Subsidence Control 79.Prov de a brief description the ln�donXnt r cedure-❑Geothermal(Closed Loop) ❑Tracer 3i t�04t 00'� 3 $'' )�� c�iit�l drV raw
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 2-V PUL U(✓eI(
4.Date well(s)abandoned:
So. ellloc on: I
r,
eN�L�" lDh B.Certific on:
Facility/Owner � 1 ���1Dh('f pp]cable) E
True ga
l
Sig ure ofCerti ed Well Contractor or Well Owner Date
Physical Address,City,and Zip
• �'��'�" �� By signing this joint, 1 hereby certh�that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 1C.0200 6Ye11 Construction Standards
County and that a copy of this record has been provided to the well owner.
C5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(if well field,one,lettlong is sufficient) l you may use the back of this page to provide additional well site details or well
`J Y.G 1 q p N �� a ��, W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well eotustrucaon records)iif ovallable. For insdnple injection or non water supply
wells ONLY with the same eonstntetion/abondoninent.you can submit one form• 10a. For All Wells: Submit this form within 30 days of completion of well
y� abandonment to the following:
69.Well ID#: t
Division of Water Resources,Information Processing Unit,
`n`2 G 1617 Mail Service Center,Raleigh,NC.27699-1617
6b.Total well depth: 'o (ft.)
lOb.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: �"V-f 1 (in.) abandonment to the following:
Iiq Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
Mn I loc.For Water Suoaly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): V°V ` (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.
6L Inner casing/tubing length(if known): —(ft.)
VW k4,0 IM
6g.Screen length(if known): (ft.) f
North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
Form GW-30