Wake_Well Abandonment_20240419

W LLL AlAN DON IVIL+ N I KL+ 1 UI(U For Internal Use ONLY: t
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1.Well Contractor Information: WELL ABANDONMENT DE1TAILS
Ali/lj�vn �/,JiTI/Y ly 7a.For Geoprobe/DPT or Cloled-Loop Geothermal Wells having the same
Well Contractor Name tor well owner personally abandoning well on his/her property) well construction:depth,opl©I 13W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): /, /‘p 7(gal.)
8e/f�' t:A/1/). ,),..44-3 P.1,I-e- 1 FOR WATER SUPPLY WEII LS ONLY:
Company Name
�, J • / . 7c.Type of disinfectant used:l.
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2.Well Construction Permit#: (!V/�r S 00 7 /6 '
List all hpplic•ahle n•ell construction permits(i.e. L'/C'.County.Stale. Vorinnc•e.etc.)i/'known
7d.Amount of disinfectant used:,
3.Well use(check well use): . ,
Water Supply Well: 7e.Sealing materials used(check all that apply/)'
DAgricultural ❑Municipal/Public ❑ Neat Cement Grout IBctttonitc Chips or Pellets
❑Geothermal(Hcating'Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement ro 1 . '. . }+I •'' ti Dry Clay
❑Industrial'Comniereial ❑Residential Water Supply(shared) ❑ Concrete Grout 0 Drill Cuttings
❑In'igation ElSpecialty Grout APR 15 2024 ❑ G'avel
Non-Water Supply Well: ❑ Bcntonitc Slurry q(Pthcr(explain under 7g)
• ❑Monitorin ❑Recover `�-i-?j•`''B'�:'^"-�,'��``�r:'
Injection Well: , � 7f.For each material self Ye��•�h'oCe;provide amount of materialsls used:
• ❑Aquifer Recharge U�Groundwater Rentediation Po /e Pe lie Ls Q^� ?/ S- 2, /i�ic
❑Aquifer Storage and Recovery • OSalinity Barrier / i 7 / L_ O J o
DAquifer Test ❑Stormwater Drainage •
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure: .
❑Geothermal(Closed Loop) ❑Tracer .(
[]Geothermal(lleating/CoolingReturn) ❑Other(explain under 7g) • ��_vJe'C-/rCi✓ eBl',r/Jf IA)ere G N/��
t3G &'` . k7' -
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, ,,,,fere/1'/1�� w, frad ve i y She✓
4.Date well(s)abandoned: 3 rg /
/Peivi/y if to ai iLcf,'r(41ci.!,tt,:•j 6k.y„o,,,t-
5a.Well location: /
_Tyre-!✓giAwize,�s'h 4 r /�-f�t�n'�( .
Facility Owner Name Facility IN(if applicable) 8.Certification: .. s
7// /X 12a.;,✓ fi e t i ice se5t 27587 AZ,e/g-.9 3 -Z7'Z'y
Physical Address,City.and Zip a Signature of Certified Well Contractor or Well Owner Date
�'� "(l 9/ ' By signing this/ornr, I hereht• c•ia•ti/i' that the wells) was firer') abandoned in
County Parcel Identification No.(PIN) oecordwtc•'with I5.4,VCAC 02C.OJ00 or 2C.0200 Well Como-tailor?Standar-dc
and 1ltat a cops•of•this record lbws been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i '
(if++ell field.one tat-long is sufficient) 9.Site diagram or additional well details:
3 )2 7,[• 7 6 7 . 5OS f q You may use the back of this rage to provide additional well site details or++cil
l dS U N (S W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
fttachwellcmtcbitelionwere»-ells/i/available. For multiple is/erriunw•aon-u•urer supply wells
ONLY with the si ne,con.cuvrtion abandonment,rut Can submit oneforot. 10a. For All Wells' Submit;'this form within 30 days of completion of well
6a.Well ID#:3-4-7 ei.,, 1,4 AO abandonment to the following:i. '
Division of Water Resources,Information Processing'Unit,
6b.Total well depth: /Q a C•11 (ft.) 1,617 Mail Service Center,Raleigh,NC 27699-161.7
10b.For iniection Wells: In}addition to sending the form to the address in 10a
' 6c.Borehole diameter: 2, _. (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: 2' 6- (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): ,A7/7 (ft.) 10c.For Water Supply&Injection Wells: in addition to sending the form to the
add_ress(es)above,also submit Ionecopy of this form within 30 days of completion
of well abandonment to the f county health department of the county where
6f.Inner casing/tubing length(if known): /f//19 (ft.) abandoned.
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6g.Screen length(if known): //9 (ft.)
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