Wake_Well Abandonment_20240306 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.We Contractor Inf ation: WELL ABANDONMENT DETAILS
lt� Number of wells being abandoned:
For
'
r ` For rnulaple injection or non-water supply wells ONLY with the some
Well Contractor Name(or well owner personally abandoning well on his/her property) construction'abandonment,you can swbnrit one form.
7b.Approximate volume of water remaining in well(s): :Q (gal.)
NC Well Contractor Certification�Number
k'd .A t/tr,,-7c f/15.SO4 FOR WATER SUPPLY WELLS ONLY:
Company Name ! 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(cheek all that apply):
Water Supply Well: Neat Cement Grout ti •8or"I'te Chips or Pellets
❑Municipal/Public
❑Agricultural L� `�
g ❑ Sand Cement Grout • , y
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin le `
) Grout G t Concree ro + nll Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ MAR 0 b 2g
❑Specialty Grout ravel
❑Irri tion �— x lain under 7
Non-Water Supply Well: ❑ Bentonite Slurry �f7ra&:if n , : 019* P g)
ORovery C"NCc:3'JG
ec
❑Monitoring 7E For each material selected above,provide amount of materials used:
Injection Well: � r� /
DAquifer Recharge Groundwater Remediation Of a L tsy Ak 11.a f�&/S. Wry' t►"
DAquifer Storage and Recovery ❑Salinity Barrier 11 L is. Pe b4&L�.l�
DAquifer Test ❑Slormwater Drainage
OExperimental Technology OSubsidence Control 7g.Provide a brief description of the abandonment procedure:
-. t t
❑Geothermal(Closed Loop) ❑Tracer � ' '4L' �tfN.t;�' �G:LI. Iva- �.t`ll* If+k � Y
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) � }�
►�ri 0/ �,�11,utic9C Ltirf si6dlt r! f� Vd- TC / nf Gt ks S.
4.Date wells)abandoned: Z Z3 Zy �� S+7g'L-G1 /Ir fi t It. fs` 4e4l JC-4 . 4 1"k-A /A a
Sa.Wcll location: Stan CA,) Co►l'-(per
y
mtI 4 1 clohg �✓ Sbr�l oo-a-oocnooS�G
Fa •ity/Owner Name Facility ID#(if applicable)
8�2k4_1
cation:
4
�4���p � . �t „-_
Signature of Conified Well Contractor or Well Owner Ibte
Physical Add res,City and Zip ff
(,(.p `a L41 �( ( II"I By signing this form, 1 hereby certify that the well(s)was(were)abandoned in
County vv Parcel Identification No.(PIN) accordance with 1 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: 9.Site diagram or additional well details:
(if well field, lat/long is sufficient)
� ,o N� �-! You may use the back of this page to provide additional well site details or well
3 J,14 b SE� N / 1 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)y available. For multiple injection or non water supply
wells ONLY with the sanne constnrctionlabandonnneni,you can submit one foron. 10s. For All Wells' Submit this form within 30 days of completion of well
Nnl� `� abandonment to the following:
6a.Well ID# I 1
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699.1617
6b.Total well depth: T (ft.)
]Ob.For Injection Wells: In addition to sending the form to the address in IOa
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: —(ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): h��C�Ji� (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
a where abandoned.
6f.Inner casing/tubing length(if known): v n o (ft•)
6g.Screen length(if known): VI\W�LW (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013