Lee_Well Abandonment_20240318

trihiWELL ABANDONMENT CORD For Internal t se()NI l �
I.Well Contractor Information: 11'ELI,ABANDONMENT DE7 AILS
Upland Rentals, LLC (owner) 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well contractor Name for Hell(wrxr personal')abandoning well on his her propem I well construction/depth.only I GW-30 is needed Indicate TOTAL NUMBER of
wells abandoned.
N('Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONI.I:
Company Name GBR SHOCK
7c.Type of disinfectant used:
2.Well Construction Permit H:
Ltst all applicable well communion permits(i.e.(I/(',('aunty,State.Variance,etc.)if known 7 LBS
7d.Antolini of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
GAgricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) UResidential Water Supply(single) PI Sand Cement Grot(1— •- - jjry_Clay
r'
❑Industrial/Commercial ❑Residential Water Supply(shared) ■ Concrete Grout Otrittleuttings
❑Irrigation ❑ Specialty Grout Mr�k ) 0Gravel
Non-Water Supply Well: El Bentonite Slurry C U�Other(explain under 7g)
❑Monitoring ❑Recover}
tit.:(e:£:: .��-
Injection Well: — 7f. For each ma(erurse1cuff,al)uv4 'lditisflbMntofmaterials used:
fi '
❑Aquifer Recharge ❑Groundwater Remediation SAND 200 LBS
❑Aquifer Storage and Recovery ❑Salinity Barrier CONCRETE 3 YD
❑Aquifer Test ❑Stormwater Drainage
DExperimental Technology ❑Subsidence Control
7g.Pros ide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed outer casing, environmental watched disinfectant applied
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g1
then observed the sand installation followed by the placement
4.Daft well(s)Abandoned 3/5/24:
of the concrete.
5..W ell location:
Upland Rentals, LLC
2946 Pilson Rd., Cameron 28326 11i (if applicable) .Certification:
•aAAAA/11 (L)0,AAA.4) 3/14/2024
Pinsi,al Address.(il\.and Lip stgnatuie of Certified Well Contract or Well(honer Dale
Lee
By signing this form. /hereby certih•that the well(s)was (were)abandoned in
County Parcel Identification No IPIN) accordance with/5A 1VC'AC 02C.0100 or 2('.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:
lifoell field.one tat lung is sufficient 9.Site diagram or additional well details:
N " You may use the back of this paste to provide additional well site details or well
abandonment details You may also attach additional pages if necessary
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
SUBMITTAL INSTRUCTIONS
IO\ti
Attach well construction records)ifasailahle l brmuliiple injection or min-water supply we/Lk
ONLY with the same construction abandonment:YOU can suhmn one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDH abandonment to the following:
Dry ision of 1\ater Resources,Information Processing l'nit.
6b.7 otal well depth: 53 (ft.) 1617 Mail Sen ue('enter,Raleigh,N('27699-1617
lob. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 24 tin.) abuse, also submit one copy of•ibis form within 30 days of completion of well
abandonment to the lidlossing
6d.11 ater Iry el below ground surface: 10 (it.) I)is ision of W titer Resources.l nderground Injection Control Program,
1636 Mail Sen ice('enter,Raleigh,\('27699-1636
6e.Outer casing length(if knoss nt: (ft.) 10c.For Water Suaah &Injection Wells: In addition to sending the form to 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 count where
6f. Inner casing/tubing length(if know tit: (ft.) abandoned
6g.Screen length(if know to: (ft.)
North t aioluia Department of Ensirunmentat(Jiwbi)-Dry ision of Water Resources Remised 2-22-2016