Pender_Well Abandonment_20240301

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
i
86UYJ WC,- f (,YVI SerV 4 LeS ' CIU 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 I GWL 30 is needed. Indicate TOTAL NUMBER of
•,�_�_ wells abandoned:
tJ A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Sound LyLW ery I � FOR WATER SUPPLY WELLS'ONLY:
Company Name
1 7c.Type of disinfectant used:
2.Well Construction Permit#: unayo"11 ��'e
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmonw 1
7d.Amount of disinfectant used: 1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check'all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cem }tL kBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑Sand Cemen Groff 6 C Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ir❑Drill Cuttings
- ❑Irrigation - - -- ❑-Specialty GroutMAR 0 1 20L4 ❑Gravel
Non-Water Supply Well: ❑Bentonit I ElOther(explain under 7g)
PTff .i rfn'�7en D! �as3vlq +LM
❑Monitoring ❑Recovery ��,��,,,P fi rr1�r��
Injection Well: 7f.For each materhd selleke' e,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation �7� j�tvx��;�;_3J$r`C�t�js
❑Aquifer Storage and Recovery []Salinity Barrier v /
❑Aquifer Test ❑Stotmwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer l�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 11 A 0'I'I r al e-cw0w f. + o rT cm l� 12
- Wow �d-z. o l � � � B cl.� s u��� �
4.Date well(s)abandoned: - '� 1l J V � o Q7_W-
l t
5a.Well location:
Felix
Facility/Owner Name Facility W9(ifapplicable) 8.Certification:
Mo Dmwo c Qr6qq3 , ( t� 2,15.2q
Physical Address,City,and Zip fj c, p Signauue of Certified Well Contractor or Well Owner Date
By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I 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:
p I t l / I -1 t� You may use the back of this page;to provide additional well site details or well
N - / -�a � W abandonmen(dctails. You may also I attach additional pages if accessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable.For multiple h jection or non-watersupply wells
ONLY adth the same constructionlabandonment,you can submit oneform.
10a.For All Wells: Submit this'form within 30 days of completion of well
6a.Weil ID#: (1 yi l.y& c, e— abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Marl Service!Center,Raleigh,NC 27699-1617
i
Y t7 10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: d (in.) above,also submit one copy of ihis form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: �( (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
ll IOa For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit otie copy of this fort within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned
6g.Screen length(if known): (ft.)