Nash_Well Abandonment_20240116

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lawrence D. O er + 7
PP 7a.Number ofwells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply' wells ONLY with the same
constructionlabandonmem,you can submit one form.
3322-A I1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 01 (gal.)
Regional Probing Services FOR WATER SUPPLY WELLS'ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Coun(K State,Variance,etc.)ifknown i
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public Il Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
ZMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Grout: approx. 2 gal./well
❑Aquifer Storage and Recovery ❑Salinity Barrier MW-6D: Approx 8.5 gal.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of,the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Tremie-filled from bottom-up.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
MWAR(1"x15%MW-2(1"x15'),MW-3(1"x15'),MW-4(IN15%MW-6(2"x15'),
4.Date well(s)abandoned: 12/01/2023,12/19/2023 MW-6D(2"x4T)abandoned 12/01/2023;MW-5(1N15')abandoned 1 211 8/2 02 3
5a.Well location: i•
Bobby Murray Toyota NCDEQ ID NONCD0001345
Facility/Owner Name Facility ID#(if applicable) 8•Certification ?`"a' r=a nY
943 N. Wesleyan Blvd., Rock Mount LawrenceqOpDpD `� ~° 6 2f&9/2023
Y Y ��,
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owner Date 1
Nash By signing this form, I hereby cetT1 rp,1.v
�that the wefl�SA'i-{Were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.968830 77•$12227 You may use the back of this page to provide additional well site details or well
abandonment details. You may also
N W attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS;
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLYwith 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#:
Monitoring Wells-see 7g abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: see 7g (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
well I.D.=see 7g above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
�i
approx 8.5 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service C enter,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (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
6E Inner casing/tubing length(if known): 5-38 where abandoned.(ft.) !,
6g.Screen length(if known): 5-1 0 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
i