Columbus_Well Abandonment_20231228 (18)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I J
1.Well Contractor Information, WELL ABANDONMENT DETAILS
�� r 5 Jvbr 7a.Number of wells being abandoned:
—4For tnulllple injection or non-water .supply wells ONLY with the same
Well Contracgt�or Name(o well owner personally abandoning well on his/her property) corulnInullI'abandonment,you can srobntit one form.
7b.Approximate volume of water remaining in well(s): (gal,)
NC Well Contractor C qntfiicqtlon Number /' ^
FOR WATER SUPPLY WELLS ONLY: ly ,,V—
r I` GY�1 ✓ 7c.Type of disinfectant used:
Company Name
2.Well Construction Permit
Lift 011 applicable well permits(i e.Catn%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 ly):
Water Supply Well: ❑Neat Cement Grout- _ _ entonite Chips or Pellets
❑Agricultural ❑Municipal/Public 4' ' t��' Zjr�Clay
(single) ❑ Sand Cement Groutl.����,�+ R4+'
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ❑ Concrete Grout ❑ D.11 Cuttings
❑Industrial/Commercial OResidential Water Supply(shared) �E L 2 202b Gravel
❑ Specialty Grout
rctionWell:
n ❑Bentonite Slu �• ❑ Other(explain under 7g)
r Supply Well: �lit�Of .t26)Pl C�&Q fS 1.ng ❑Rec°very7E For each materialiise//lec i4�rovide amount of materials used:
r LS JA/
Aquifer Recharge oundwater Remediation
❑
❑Aquifer Storage and Recovery IIICCCIdSS"""alinity Barrier 31 V tOEnt . Ckii�/
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,P.Ovid a brief description of th abandonment
//proce ure:,, /,
❑Geothermal(Closed Loop) ❑Tracer �Ut j/ �� Gq(/a j (�/t l
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) DG� Put- /�h d ht v ) t�-
4.Date well(s)abandoned: '^ '^
U M. �
52.Well location:
f
S.Cert' tion:
±e iliC� �ifapplicable)
Fecdiry/Ow e`r Na j� i �I /Y�hA1L99// [I//nn
Ob ��" O'"��` "��� �� g ureofCertified Well Contractoror Well Owner Date
Physics , d ress,NCi1, and Zip
V`t��tlJ' t{/ r� By signing This form, /hereby certify that the well(y)was(were)abandoned in
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: 9.Site diagram or additional well details:
(ifweelll f eld,one lat/long is sufficient)N �p t I You may use the back of this page to provide additional well site details or well
on
►�I n ( 1 I Ss t W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLY with the some eonstnuction/abandoninent,you can submit one forut 10a. For All Weds: Submit this form within 30 days of completion of well
abandonment to the following:
6s.Well IDII: Division of Water Resources,Information Processing Unit,
r
�t�1 1617 Mail Service Center,Raleigh,NC.27 99.1617
6b.Total well depth: (ft.)
IOb.For Infection Wells: In addition to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.)
�� VYA abandonment to the following:
Division or Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:IR (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water Suaaly&Injection Wells: In addition to sending the form to
6e.Outer casing Iength(if known): t/ Y��f,V (ft.) the addresses) 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 knoown))I:— . (ft•)
V
6g.Screen length(if known):
1,U<.0-01,t/o (ft.)
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013