Craven_Well Abandonment_20240325

II
WELL ABANDONMENT RECORD For Internal Use ONLY: I,
1.Well Contractor Information: WELL ABANDONMENT DETAILS
G ri/ L. n 4:41/d 1., a Ft ti I I
7a.For Geoprobe/DPT or Close Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GVk730 is needed. Indicate TOTAL NUMBER of
/ 1.,co +;• wells abandoned
NC Well Contractor Certification Number 7b.Approximate volume of wate .remaining in well(s): (gal.)
40 Fit - IA/ FrLZ V AL*
FOR WATER SUPPLY WELLS ONLY:
Company Name i
7c.Type of disinfectant used: 1
2.Well Construction Permit#: hil" ,
List all applicable well construction permits(i.e.UIC,County.State,Variance,eta)ifknown I I
7d.Amount of disinfectant used:,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
f;l(gricultural OMunicipal/Public ❑Neat Cement Grout ' 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑lrrigation 0 Specialty Grout fiLBfravel
Non-Water Supply Well:
❑-Bentonite Shiny ❑Other(explain under_7g)_ _
[Monitoring . = DRecovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge- ['Groundwater Remediation 1:-
[]Aquifer Storage and Recovery OSalinity Barrier C I
❑Aquifer Test ❑StormwaterDrainage I '
❑Experimental Technology ❑Subsidence Control 1 I"
a 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /,,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) �, ifn //Qc/pfetvioLsecy
been /eelrap ed4vere
4.Date well(s)abandoned: s yeARS
[ + //S pee kJ
e.t 1
5a Well location: I � ; ,
iilrl ' it.miG1r1d sect .... r
, i
Facility/Owner Name Facility ID//(if applicable) S.Certi'cation:
�1.5 NC. I i4 !IZ,Vorce, em, �';, ,.`-
Physical ' g_140)_aifY
p Address,City,and Zip nrC r� (p Si turc of Certified Well Contractor o'Well'l Cr Da
'_mire r1 1`QLoI.01 q • signingthisform,I hereby "1.
BY cent that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C:0100 or 2C.0200 Well Construction Standards
and that a copy of this record has ibeen provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/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 also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED-._ - SUBMITTAL INSTRUCTIONS
- -Attach well constructionrecord(s)ifavailable.Formultiple injection or non-water supplywells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID 'I#: lid n ham(.4.31
3 abandonment to the following:
F--a i.77 ->. y ,.t—_,.�,:. ,
°,• •I,. r .. . t I Division of Water Resources,
•� &,.,�; ,� � '� Information Processing Unit,
6b.Total well depth: (ft.) Ss-,,* 1617 Mail Service Center,Raleigh,NC 27699-1617
MAN-2 v 2024
10b.For Injection Wells: di In ad on to sending the form to the address in 10a
6c.Borehole diameter: (in.) lnti`"'"s: v;�r^'•.,u,„-; ,n� ovabeomno submit tb the one copy of
�I form within 30 days of completion of well
11
6d.Water level below ground surface: (ft.) Division of Water Resources,;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10e.For Water Supply&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-county where ,
6f.Inner.casing/tubing length(If known): (ft.) abandoned. 1 - -
I
6g.Screen length(if known): (ft.) i
'I
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
• II