Person_Well Abandonment_20231229

1
WELL ABANDONMENT RECORD For Internal Use ONLY: ° .
1.Well Contractor Information: WELL ABANDONMENT DETAILS
. 7a.For Geoprobe/DPT or Closed-L I
ct£n ,/ op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW130 is needed. Indicate TOTAL NUMBER of
wells abandoned: /
30 /.-!4 t'/
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): G (gal.)
lAiQ.k/ �Y Ze-s 4 C FOR WATER SUPPLY WELLS ONLY:
Company Name ,14 4- 4
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if knownq „r�
7d.Amount of disinfectant used: V1-AJ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑M icipal/Public Neat Cement G ut s - ^ ;_^ N 1 v el
unite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement G u`t I—i, t- Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout DEC 9 2 9 2ozJ Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry r• r ' +)1Et (explain under
❑Monitoring ❑Recovery {nQ{iF.^re.ILi1►�.rf9fi ( P 7g)
DWCAOG
Injection Well: . 7f.For each material selected above'provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation '1 J 4100 I 5
:Aquifer Storage and Recovery ❑Salinity Barrier 7
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �A
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) V'5a,C)? , l- 4-ctAc-4 4-o V)J I '4
30(4. L-eA4 ( in e.Alt..,. 3 F<
4.Date well(s)abandoned: til' s20 3 ' r j I J„i��] r e to J' 4 4-.1 .1i _ 47 �
5a.Well location: �Y 1) e /�
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
3 7/2 gib,r)t,ei 4,/he..., eil 19 < -i-v-P-j0 a //13W'=,
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
e ..ry oil By signing this form,I hereby certify that the well(s)was(were)abandoned in
Cy Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
3C Lig l 34147 N — c !1'I q 6 4 4/ w 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following: t
I
�J Division of Water Resources,Information Processing Unit,
6b.Total well depth: D2.4 It (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: �� (in.) above, also submit one copy of this!form within 30 days of completion of well
abandonment to the following: !'.
6d.Water level below ground surface: le (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): CQ.60 (ft) 10c.For Water Supply&Injection Wells: In addition to sending the form to 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
6f.Inner casing/tubing length(if known): (fL) abandoned.
6g.Screen length(if known): (fL)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
{

I
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
5,(�IAva l l 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30'is needed. Indicate TOTAL NUMBER of
wells abandoned: [I
NC Well Contractoror Certification Number 7b.Approximate volume of water remaining in well(s): 2 6 r (gal,) •
Wake- V of Lcd /fig, , FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: H T/
2.Well Construction Permit#:
List all applicable well construction permits(r.e.'UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: i OtAN e•GS
3.Well use(check well use):
f
Water Supply Well: 7e.Sealing mat 1-it erclietkld t r �]�%,:
❑Agricultural ❑Municipal/Public Neat Cement 'dtr 1 i,' f entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Gro ❑Dry Clay
❑lndustriallCommercial ❑Residential Water Supply(shared) 0 Concrete Grout UE.
0 2 9 ;20��0 Drill Cuttings
Ohrigation Non-Water Supply Well: ❑Specialty Gro tt en p fljj vel
0 Bentonite Slurry DWOJ OG 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation / �� c t t7/ .
�ig f®D/[
❑Aquifer Storage and Recovery ❑Salinity Barrier �gA TJl/ue
❑Aquifer Test DStormwater Drainage 1'c) e.e,,, h 1-400l6 rj
❑ExperimentalTechnology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer , , 9
OGeothermal(Heating/Cooling Return) ❑Other(explain g1,`under 7g) 1Q!'i n t/_�/c.I//I Au tT J--1r.le it)!Pit,
4, c ftrA✓y+ 3°'e...jcieyGA,r LJc//
4.Date well(s)abandoned: /2 - / - 2c 23 1
/5a.W locatio : n
eV r�ey ,, .Sf/ 11C 4,�9 3tn� e'cp over l,.'�d/( eon« t„loAA c�t-1k,�.,
Fac "ty/Owner Name Facility ID#(if plicable) 8.Certification:
4iLt c�'
L3/00 -% 4^ l' - 2-ta
Physical Address,City,and Zip 7-7S 7 Signa of Certified Well Con r or Well Owner Date
Pe r
f
ryb By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15,4 NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
(if well field,one
lat/long is sufficient) 9.Site diagram or additional well details:
3 .LAI c/ 2 N --7g- 9 2,2-7 s®5- W 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 I
Attach well construction record(s)if available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. ;
10a.For All Wells: Submit this form within 30 days of completion of well
6a Well ID#: abandonment to the following:
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: t g 0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
P� 's 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter: `��� (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: II
6d.Water level below ground surface: 'S (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Cos (ft) 10c.For Water Sunplv&Infection Wells: In addition to sending the form to 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
6f.Inner casing/tubing length(if known): /'(D (ft.) abandoned. i
�p i
6g.Screen length(if known): i//A (ft.)
•
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016