Wake_Well Abandonment_20240306 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wel ontrsctor information: WELL ABANDONMENT DETAILS
Ir y A, �5�.!F'y. 7a.Number of wells being aba ndoned:
Well Contractor N Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the save
a constntcrion'abandonntent,you can submit one form.
333 q 7b.Approximate volume of water remaining in well(s):
NC Well Contractor Certification Number
+]C!tj'/r,` 5 y FOR WATER SUPPLY WELLS ONLY: 1
Company Name ( 7c.Type of disinfectant used: r"
2.Well Construction Permit#: J'J
Litt all applicable well permits(i.e.County,State,Variance,injection,etc)ijknown 7d.Amount of disinfectant used: r y
3.Well use(check well use):
7e.Sealing materols used(eheokall5thpOBLonite
Water Supply Well: i , Chips or Pellets
❑Munici al/Public Neat Cement Groot
❑Agricultural p p D Clay
( g ) ❑ Sand Cement Grout O G 2OZ4 Dry y
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Drill Cuttings
❑Residential Water Supply(shared) ❑Concrete Grout g
❑Industrial/Commercial pp y(
vel
❑ Specialty Gr9�a/�"atFn?r-;soo:e•:g°'
Olrrigation ❑ Other(explain under 7g)
Non-Water Supply Well: ❑ Benlonite Slurry C. �:ttxa
❑Monitoring ❑Recovery
7f.For each material selected above,provide amount of malerisls used:
Injection Well:
❑Aquifer Recharge Groundwater Remediation 7 K � � I (.��tlCs ``��i. rG It•'di"t�� �';>��i/�'e
❑Aquifer Storage and Recovery ❑Salinity Barrier r ��u t` p`y�e`� 4�,_Gj rlyh
❑Aquifer Test ❑Stormwater Drainage -f cL
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1 C.tl�y jF.�9kif�'P(� �jPtiA./T' t;�i�Ylj �t1+t>t 7 j�✓�
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 2�Z-y Co► t� (�J U0 �//u
Sa.Well location: s4anGt � Qt� � Cln r k'��� / /�t��' r�— u,O t . �'` �+ tt7Ncf st.Wiz- t
nit att's bwv v- SVOVA oo—o-000(;0o 5S' -f Cf
�S.Certific4afin:Facili /Owner Name Facility ID#(ifapplicable) \1�'"'ql ( � -
Physical 7�Lw
^ /- ( Signa oWell Contractor or Well Owner Date
i 1 U OtL4 1 (L l `1 By signing this form, /hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy ojthis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 9.Site diagram or additional well details:
(ifwell field,one lat/long is sufficient)
3 � I � . �g. You may use the back of this page to provide additional well site details or well
1Y1 N 7 J 'f W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)tjavailable. For multiple injection or non-woter supply
wells ONLY with the sane constntctionlabandonment•you can submit one form. 109. For All Wells• Submit this form within 30 days of completion of well
69.Well ID#•
abandonment to the following:
Division of Water Resources,Information Processing Unit,
I 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: ✓ (ft.)
61 10b.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:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: I� (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
1/ 10c. For Water Supply& Injection Wells: In addition to sending the form to
6e.Outer easing length(if known): Y n U�'✓� (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� t where abandoned.
6f.Inner casing/tubing length(if known):Vj� C 1,-44(ft.)
6g.Screen length(if known):—U Ah 0 WA (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013