Wake_Well Abandonment_20240306 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor I format' 1/ WELL ABANDONMENT DETAILS
(�lOru irSCs`�� 7a.Number ofwells being abandoned:
�
r supply wells ONLY with the same
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-wale
coru truction'abandonment,you can submit one form.
*3 33 -1 7b.Approximate volume ofwater remaining in well(s): :Qi (9sL)
NC Well=— C"A
on Number
t tL � 5stz' FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N
2.Well Construction Permit#:
List all applicable well permits(i.e.Co+mo,State,Variance,Injection,etc)ijknown 7d.Amount of disinfectant used:
3.Well use(check well use):
7e.Sealing materials used(check all that appl
Water Supply Well ):
Neat Cement Grout-- - Bent1o1nite Chips or Pellets
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) eland Cement Grout ,`+�(l..r(�I, Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout MAR 06 20�Drill Cuttings
01rrigation ❑ Specialty Grout Gravel
Non-Water Supply Well: ❑ Bentonite Slurry to. s - 13 (explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material se ectedtabove,provide amount of materials used:
❑Aquifer Recharge groundwater Remediation 2 s-1 k-, J�lAly (,�� owd ei'd b( ►�
❑Aquifer Storage and Recovery ❑Salinity Barrier „I�S A)r `��
❑Aquifer Test ❑Stormwater Drainage �+-
❑Experimental Technology ❑Subsidence Control 7 . rovide brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �1� htf�(, I 01Glt 41 1`PV4-
❑Geothermal(Heating/Coolin Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: Zi lJ s�irAce.
" � tij �e ' Y,4n�
52.Well location:S�CL(1G I Qa� (A(VL)" {Nfe egg CN Cd fr is,fit 4��i 1 %1►t r
M�ICI IS oVnc✓ &b►'-e_ 00-0-D0000C) 59gC1 - 1; k 5tirfac
Facility ID# tfa Itcable 8•Certi ation:
Fac ty/Owner Name tY ( pP )
qbt� p��1r /'�. y�r� � 1 �', � C 24�1zy
Physical Address,City,and Zip �1'` ( Si ture of rtified We 1 Contractor or Well Owner Date
J&1���e 1-1(-p oC'1 (0 4 By signing his form, 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
J"'
tt�,,'I
,I You may use the back of this page to provide additional well site details or well
3� 41l b S V I- N .'I yl�4y abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply,
wells ONLY with the some construcaon/abandonment,yott can.submit one form. 109. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
+ Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
fib.Total well depth: � � (ft.)
10b. For Iniection Wells: In addition to sending the form to the address in 10a
Qabove,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: i/ (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground (ft.surface!: (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
V�IC � dl 10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): ) 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
11 ,,
6f.Inner casing/tubing length(if known):y� (ft.) where abandoned.
fig.Screen length(if known): (tt.)
form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013