Davidson_Well Abandonment_20240205 (2)

1.S Contractor Information: WELL ABANDONMENT DETA91S
7a.For Geoprobe/DPT or Closed!,Loop Geothermal Wells having the same
Well Contractor Name(or well owmer personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well C—ontra�ctoor Certification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
Morgan Well & Pu rn p,d N C FOR WATER SUPPLY WELLS,ONLY:
Company Name ranulated chlorine
7e.Type of,.disinfectant used: g•
2.Well Construction Permit#: V cl V
List all applicable well construction permits(i.e.LUC,County,State,Variance,etc.)if/anown
• 7d.Amount of disinfectant used:
3.Well use(check well use):
Water-Supply Well: 7.,�ee.Sealing materials used(check all that apply):
❑Agricultural ❑Municipa]/Public 15 eat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) AResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Woncrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Qthei:Ap alaiaamd r P-.
❑Monitoring ❑Recovery l
Injection Well: 7f.For each material selected above,pro de'amount of materialls used:
❑Aquifer Recharge ❑Groundwater Remediation —� F Cp 5 2024
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage In`Utpr"l'"n err c .,� 3 14
U
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief&scrlption f the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ll /� `I
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �•L� ( V be `,ova/
4.Date weI(s)abandoned: `� B_ ''
�_h I r)� h c o aA- -kV1t'V\ Fi 11'aA
5a.Well location:
l�b�n �ro-M -�cv ctL
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Y I.
��Z 1�-�VeC Uroo�, !D{ �Yt-� Ce,�C i n���We• / i� -ZZ-z
Physical Address City,and Zip Sigratu ertified Well C ctor or,Well Owner Date
n (
11"cam 'Xv 2,-7z q By signing this form,I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with ISANCAC 02C.0100 or2C.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:
N W You may use the back of this page;to provide additional well site details-or well
abandonment details. You may also attachadditional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS 1
Attachwellconstructionrecord(s)ifavailable.For multiple injection ornon-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDM abandonment to the following:
Q Division of Water Resources,Information Processing Unit,
6b.Total well depth: V (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
r 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: V n (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: &A —(ft.) Division of Water Resources,Underground Injection Control Program,
�J ]_ 1636 Mail Service Cel ter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): /V P (ft.) 10c.For Water Supply&Ini ection'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):141A (ft.) abandoned.
I
6g.Screen length(if known): Ilt /�,�l )o (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016