Rockingham_Well Abandonment_20240318

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: WELL ABANWNMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only l G'W-30 is need. Indicate TOTAL NUMBER of wells abandoned:
NC Wei Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Company Name FOR WATER SUPPLY WELLS ONLY:
2.Well Construction Permit#: �jf�J(/�G�7 C� 7G Type of disinfectant used:
List all applicable well corubwction permits(f.e.UIC.Couno-,State,Variance,etc.)i{known
3.Well use(check well use):
7d.Amount of disinfectant used:
Water Supply Well: 7e.Sealing materials used(check all that apply),
❑A cultural pP y)'
❑M icipal/Public ❑Ncat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑SSaand Cement Grout 1 tt3 Dry Clay
❑Industrial/Commercial ❑Residential Water S I hared tYC ' r
Supply(shared) oncrcte Grout ❑Drill Cuttings
❑FICIAquifer
te ❑ Specialty Grout titp� t S ❑Gravel
ter Supply Well:
❑ Bentonite Slurry O Other(explain under 7g)
ring ❑Recovery ': ?. _
Well: '�
7f.For each material selected above,provide amount of materials used:
Recharge ❑Groundwater Remediation
qer Storage and Recovery ❑Salinity Barrier --
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑TraCe. 7g,Provide a brief description ol'the abandonment procedure:
❑Geothermal(Heatin Coolie Retum) ❑Other(explain under 7j) AJ `1
4.Date well(s)abandoned:
Sa.Well location:
Facility/Owner Name Facility ID#(if applicahle) 8.Certifcation:
Physical Address,City,and Zip
signature ofCortificd Well Contractor ell Owner e
County — By signing this form, I hereby certl/ry that the wells) was(were) abandoned in
Pamcl Identification No.(PIN) accordance with I SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude and that a copy of this record has been provided to the well owner.
g[ in degrees/minntes/seconds or declnal degrees:
(if well field,one fat/long is sufficient)
9.Site diagram or additional well details:
N ►nJld'!!� S S6 You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WEL IS)BEING ABANDONED
Attach well constmelinnrecord(.$)ifavailable.For multiple injection or non SUBMITTAL IN
P J pply x�rl/s
ONLY with the same cnnstnec(ion/abandonment,yet can.trtbrnit one form.
109. For All Wells: Submit this ibrm within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Reso urces,Information Processing Unit,
6b.Total well depth: 7 (g,) 1617 Mail Service Center,Raleigh,NC 27699-1617
/' l6b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: G (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (B•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service('enter,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (n) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
addmss(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the cotmty health department of the county where
6f.Inner casing/tubing length(if known): (D,) abandoned.
6R.Screen length(if known): (g)
Form OW-30 North r—i;..a ^-