Orange_Well Abandonment_20231229

WELL ABANDONMENT RECORD For Internal Use ONLY: j
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1.Well tractor Information: WELL ABANDONMENT DETAILS
4C51 /VegIWOOermal Weg tmeWell Co owner personally abandoning Well on his/her properly) well construction/depth,only I GW'-30°s heeded. Indicate TOTAL NUMBER of
j ,,t wells abandoned:
Aontractor Certification Number t �
NC Well C 7b.Approximate volume of water remaining in well(s):_la,Z____Igal.)
N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY::
Company Name HTH
7c.Type of disinfectant used: ,
2.Well Construction Permit th clt9---.." -. L/
',wan applicable well construction permits(i.e.WC,Comity,Stale, Variance,etc.)ij1•nown 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials uscdLcheclyi,l lha)t ly):
❑Agricultural ❑Municipal/Public 0 Neat Cement t(,.'.tl. +'L:x V entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Witter Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout DEC 2.9.2023 0 Drill Cuttings
❑Irrigation specialty Go ,.en 7roc . iavcl
Non-Water cr Supply Well: 0 13entonite Slurry DWOBOG 0 Other(explain under 7g)
❑Monitoring ❑Recovery
. Injection Well: 7f.For each material selected above,provide amount of materials used:
• ❑Aquifer Recharge OGrouudvaler Remcdiation ,g�,+�''V tt
iaotitc .• . ,.
t i) s .
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 ed
❑I1quifcr Test ❑Slorimvater Drainage �� /` / � c J
' ❑Experimental Technology ❑Subsidence Control
7g. 'rovide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer,". . ... ..
❑Geothermal(I-Icating/Cooling Return) ❑Oihcr(czplaiil under 7g) 10T 7 %.' , Ill .l
001
� '4.Date wells)abandoned: 7ZPtf, AøtE /2,0 q/,f,/
5n Well location: / �g7 F.A .
Facility/Owner Name i rP .,I Facility ID/l(if applicable) 8.Certification: T®
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Physical All<Iress,City,and Z.ip' '7 i
E6 AI � Signature of titled Well Contractor or Well Owner Date '
l�` By signing this form. I hereby certify That the itell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCiIC 02C.0100 or 2C.0200 Well Construction Standards
• and that a cop) of this record has been provided to the shell owner.
5b.Latitude and longitude in degrees/minutes/seconds,0i,';dccimal degrees:
(if well field,one Ial/long is sufficient) 9.Site diagram or additional well details:
.N ®eD.D a N •
n.. OcC a 34 »i You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
loath well construction record(s)i([available. For multiple injection ornon-walersupply shells
OPILV with the.saute construction/abandonment,you tali sithmit else joi,i.
i.P. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well Mil: abandonment to the following:
,:I)_,„i
1 - i.,: is ';r, Division of Water Resources,Information Processing Unit,
Gb.Total well depth: ,, , (ft,) .i 1617 Mail Service Center,Raleigh,NC 27699-1617
, 6 ;h', i' ; i�,l I:' 1, 10b. For Injection Wells: In addition to sending the form to the address in 10a
Ge.Borehole diameter: �7-(in.) ,t . ., above, also submit one copy of this form within 30 days of completion of well
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a . ' 0 F.."l' abandonment to the following:
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(id.Water level below round surface: .e , Division of Water Resources,Under i ound Injection Control Program,
g (ft.) 1636 Mail Service Centel,Raleigh,NC 27699-1636 g
tie.Outer casing length(if known): • •• . ..•(ft.) .10c.For Water Supply&Injection Wells: In addition to sending the fonts to the
,lt.., t.;.. . 1 tl-,,r Ili 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
Gi inner casing/tubinglength(if known): ':..:.. ;� `'r n abandoned.
g ) °:i,(ft.)
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5_,.Screen length(if known): (ff.)
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Form G W-30 Nortlt'Carolina D'cpartmcnt of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016