Union_Well Abandonment_20240325

WELL
ABANDONMENT RECORD i
For wMal Us,ONLY:
VAK nb
1.WeContractor Information, A�. r fi WELL ABANDONMENT DETAILS
7a.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
Well Co ctor a(or well caner personally abandoning well on hiatherproperty) well construction/depth,only I GW!30 is needed. Indicate TOTAL NUMBER of
I wells abandoned:
NC'cl!Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): tY (gal.)
M (1•�JI � �a ��Ly FOR WATER SUPPLY WELLS;O
Company Name j
Ty
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(71.e.UIC,'County,State,Variance,etc.)if1mown
7d.Amount of disinfectant used:
3.Well use(check well use): i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑�Ge�othermal(Heating/Cooling Supply) ❑Residential Water Supply(single) �❑ Sand Cement Grout ❑Dry Clay
il�Pndustrial/Commercial ❑Residential Water Supply(shared) WQ&ncrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite-Slurry, ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amountof materials used:
❑AquiferRecharge ❑Groundwater Remediation !P Ad I lFLp
❑Aquifer Storage and Recovery ❑Salinity Barrier j
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control t
7g.Provide a brief description of;the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer � J �/'
❑Geothermal(Heating/Coolirig Return) ❑Other explain under 7g)
4.Date well(s)abandoned: !�
5a.Well location: -
A Am
ka
Facility/Owner Name Facility ID#(if appl cable) 8.4;e 'fication: _
Physical
Address,City,and Zip Signature of C rtified Well Contractor or Well Owner Date
V P') /'� By signing this form,1-hereby certify that the wells) was (were)abandoned in
County Parcel Identification No:(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N � `� W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WE BEING ABANDONED
Attach well construction record(s)ifavailable.For multiple injection or non-water.supply wellsSUBMITTAL INSTRUCTIONS;
ONLY with the same constructionlabandonment,you can submit one form.
10a: For All Wells: 'Submit this form within 30 days of completion of well
6a.Well ID#: / _ abandonment to the following: i
L r fr' ,� ' Division of Water Resources,Information Processing Fait,
6b.Total well depth: y 1617 Mail Service Center,Raleigh,NC 27699-1617
MAC 2 1024 10b.For Injection Wells: In addition to sending the form to the addressin 10a
? ove,also bmit one copy 6c.Borehole diameter: (in.) itTiL' �.'^.?!?"-.';:.;�;=. i) a�andonment to the follow ng of this form within 30 days of completion of well
4 Water level below ground surface: , (ft) Division of Water Resources,!Underground Injection Control Program,
t1� 1636 Mall Service Center,Raleigh,NC 27699-1636
6e Outer casing length(if known): n (ft.) 10c.For Water Suaaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one""copy of this form within 30 days of completion
qq`` of well abandonment-to the county health department of the county'where
6£Inner casing/tubing length(if known): I U (ft.) abandoned.
6g.Screen length(if known):
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016