Davie_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY: l—rl I C��V E D
1.Well Contra r I formation: WELL ABANDONMENT DETAILS APR 2 2 2024
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contactor Name(or well owner perso-mlly abandoning well on his/her property) well construction/depth,only 1 GW-30 is need&ftiliidic�C6EgTIAJ;vUMBER of
wells abandoned:_ 6PFReTno rnorinreT mo..�t•
-- . •. ,. IPROGRAM
NC Well Contractor Cettif, umber 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name / /1
���/`� 7c.Type of disinfectant used: � GT
2.Well Construction Permit#: 7
List all applicable well construction permits(2.e.UIC,County,State,Variance,etc)rfknown { O
7d.Amount of disinfectant used: �c-
3.Well use(check well use)::
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mun' ' al/Public ❑Neat Cement Grout ❑Be�ntonite Chips or Pellets
❑Geothermal(HeatineCooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout l_Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
01rrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7£For each material selected above,provide amount of materials used:
OAquifer Recharge []Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Pro de a brief description of the abandonment procedure:
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) d/
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4.Date well(s)abandoned: APR o U '
5a Well location:
Facility/Owner Name Fact7ity,ID9(ifapplicable) 8.Certificati/fiedWeI1CZ—
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�1k1� � r �� y
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Phys="'T
tty,an Signature&Ceell Owner Date
K By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 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 well owner.
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(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 DETAR S OF WELL(S)BEMG ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injecuon or non-water supply wells
ONLY with the same constn ionlabo7donment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: C n abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: U (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.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: C-2 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (fL) 10c.For Water Suoaly&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
of well abandonment to the county health department of the county where
611 Inner casing/tubing length(if known): Alfni?&-e (ft) abandoned.
6g.Screen length(if known): (ft-)
Form OW-30 North Carolina Department of Environs ental Quality-Division of Water Resources Revised 2-22-2016
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