Surry_Well Abandonment_20240318

WELL ABANDONMENT RECORD For Internal Use ONLY: —
1.Well Contractor Information::y� WELL ABANDONMENT DETAIL
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
W ontractoorr Name(or well owner personally well on his/her property) well construction/depth,only 1 G%'-30 is needed. Indicate TOTAL NUMBER of
,n 0 1 A ? wells abandoned: —
NC Well C5miractorCenification Number 7b.Approxinsate volume of water remaining In well(s): 2- 0(gal.)
C!(G(Ar, FOR WATER SUPPLY WELLf1 ONLY: �rT
Company Name 7c Type of disinfectant used:_Z✓�D l/
2.Well ConstructlonPermit q: (/a-wL..f.��3✓���
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List all applicable wsel/construction permits(i.e.UIC.Casino%State.Variance,etc.)tf knouss
7d.Amount of disinfectant used: `
3.Well use(check well use): —
Water Supply Well: i 7e.Sealing materials used(check sill that apply):
❑Agricultural ❑M icipal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above;provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation S / s
❑Aquifer Storage and Recovery ❑Salinity Barrie / --
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,provide a brief descriptloo o(trs ti�lAils�lEpe cede�sm
❑Geothermal(Closed Loop) ❑Tracer D
❑Geothermal(Hearing/Cooling Return) ❑Other(explain under 7 ) ��'yGr�t` /"�}'��✓��'�'�•/� [ i l�/�-�i'l..t_(�y►
r )/ Gvf!'On�LJ1-E-7C• ���;�sz7 ! C�.f%��.�./�%'�c''�
4.Date well(s)abandoned: d 7 1 ee
Sa.Well location: �
Facility/Owmrblanic Facility tDN(if applicable) S.Certification:
odm IV
Physical Address,City,and Zip atare o Ccrti tx1 Well Cofactor crf\Yell Owner Da
.; %Lx—� By signing this form, I hereby cerI6 that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) aceorxlance with 1 SA NCAC 02C.0100 or 2C.0100 Well Construction Standards
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: and that a copy of this record has Been provided to the vmIl rmwer.
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
N W You may use the back of this page to provide additional well site details or well
-------— — - abandonment details. You may aL:o attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well conslntction record(s)(available. For multiple injection or non-water.ntpply wells
ONLY with the same construction/abandonment,you can submit one faun.
lOs. For A,ll Wells: Submit this :frnm within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: �. (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1 / 106.For Infection Wells: In addition to sending the focus to the address in l0a
6c.Borehole diameter: ` (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: (It.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length Of known): (ft,) 10c.For Water Supply&Infection 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 county where
6f.Inner casing/tubing length Cif known): (ft.) abandoned.
6g.Screen length(if known): _ __(fL)