Wake_Well Abandonment_20240306

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
ZI.W1 Contracto Inf matzoWELL ABANDONMENT DETAILS
C,��(� 15 Fy" 79.Number of wells 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 some
constniction'abandonmenr,you can submit one jornr.
7b.Approximate volume of water remaining in well(s):
NC Well Con ctor tfication Number
fife d_ �`,4� f v� FOR WATER SUPPLY WELLS ONLY:
Company Name ��1��'TTT -r 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permits(i.e.Caemty,State,Variance,Injection,etc)ifknown 7d.Amount of disinfectant used: ,v
ld
3.Well use(check well use):
Water Supply Well: `7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 4�Neat Cement Grout XBentonite Chipsor Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) /❑`Sand Cement Grout_, .Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout, k-1 L:f V _Pill Cuttings
oirrigation ❑ Specialty Grout /� ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry MAR 0 G 2024 ❑Other(explain under 7g)
Monitoring ❑Recovery
njection Well: 7L For each mar lrtiddettd.6bavtit<ide$mount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation s
❑Aquifer Storage and Recovery ❑Salinity Barrier r
❑Aquifer Test ❑Stormwater Drainage
lWt lyk'..� �� � Ce�►►e.,,� 5",�401s. Irc w
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer , s� '.11 by (�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
2 Y a bo- ,- si+r u 'r-el n a [erHt�
4.Date well(s)abandoned: /�,, etf��/ / I p G /� _p
Sa.Well location: t1C Ql( w 0 QI i:Ls�' {&ell 1"Him K j Ir' /Yr s7 t 1 , C
COVrw✓S-fore 00-0'OUOCo0%1�9
F cili IDN rfa Ircable 8•Cer at ion:
ty
Facility/Owner Name ( pP )
Physical Add re s,City,and Zip Si cure ofC ificd Well Contractor or Well Owner Due
�+Cc E' (7 L.P apt U By signing this form, I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 1C.0100 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:
(ifwe`ll field,
�one lattllong"is sufficient) (� f 9.Site diagram or additional well details:
3 J i T`� t7 1 N —R q t4 b ` Z 1 You may use the back of this pageto provide additional well site details or well
�3 t W abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if ovadable. For nttthiple injection or non-Hater supply
wells ONLY with the same constrnction/abandownent,you can submit one jornr. 10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
W - 2 U abandonment to the following:
Qi y /C E1 t Division of Water Resources,Information Processing Unit,
iJ W / 1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depthT StiY C d (ft.)
lob.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in•) abandonment to the following:
�( II Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: t" ( (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
I]h Kn L�1t 10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known):J/ (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
k n�l�.yt
6f.Inner casing/tubing length(' y4
ifkn'� 1own): it (ft.) where abandoned.
f
6g.Screen length(if known): v ' `y i UIC'—li'l (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013