Wilkes_Well Abandonment_20240423

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well C tractor Information: WELL ABANDONMENT DETAILS'
� �'S �y 7a.Number of wells being abandon)d:
Well Contractor Ne a(or well owner personally abandoning well on his/her property) For rnulttple injection or non-water, supply wells ONLY with the same
L] constnrction'abandonment,you can svbnrlt one form.
_3✓7✓7 1 7b.Approximate volume of water remaining in well(s): l/ (gal.)
NC Wel Cpn�ractor rti catioWN-nbberk,
cllaFOR WATER SUPPLY WELLS ONLY:i
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: /y 4—
Livia//applicable well permits(l.e.Cortn%Stare,frariance,Injection,etc.)jErrorvn 9d.Amount of disinfectant used:
3.Well use(check well use):
7e Sealing materials used(check al'1 that apply):
Water Supply Well: Bentonite Chi so-Pellets
❑MunicipaVPublic Neat Cement Grout P
❑Agricultural ❑ D Cla a
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout Dry Y
❑Concrete Grout ❑ Drill Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ APR 2 2024
Specialty Grout ❑ Gravel
❑Irri ation ❑ Other(explain der..7
N n-Water Supply Well: ❑Bentonite Slurry p }�fr,, $..�,;��; r--•-�,;;;-.Jt ��
❑Recovery i'`"
Monitoring 7f.For each material selected above,provide amount of materials ��.`
n cti Well: ` Sn S T A cL rOfT/G7 �it:an
❑Aquife <D/1.r Recharge ❑Groundwater Remediation , D t
❑Aquifer Storage and Recovery ❑Salinity Barrier 5--0^ y Ctls U'Gv" itLly Pou dow
❑Aquifer Test ❑Stormwater Drainage
❑Subsidence Control 7 Provide a brief description of the abandonment procedure:
❑Experimental Technology g• / 9 n
❑Geothermal(Closed Loop) ❑Tracer N fA,y�D t7 urpr�3l y�1��pM15��D l�jS, r-/ dOtu�
ZA
❑Geothermal(Heating/Cooling fReturn) ❑Other(explain under 7g) �v e --1 .� �j � � � t D/ ^-��
4.Date wells)abandoned:
t
Sa. Ilocatio dDuAt �` At A / L
�, no s �o-o-0000a2�'?�4 � stfr�
Facility/Owner Name Facili 1DN(ifapplicable)
S.Certif tion:
S (�� ►M� f►� V eu+ s N �
Physical A1,deE and Zip Signature of Certified Wel Contractor or Well Owner Date
� 'Al I-GS-r173 By signing this form, I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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: 9.Site diagram or additional well details:
(ifwell field,one laattllong is sufficient) a
3 b a � ,, 0'7 � N pI I- p You may use the back of this page to provide additional well site details or well
L f 0 6 0 6/-f qS_ W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non water supply
wells ONLY with the same constructionlabandontnent,you can submit one form. 10s. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID# �1
Division of Water Resources,Information Processing Unit,
r 1617 Mail Service Center,Raleigh,NC.27699.1617
6b.Total well depth: �0 (ft.)
lOb.For Infection Wells: In addition to sending the form to the address in 10a
1t( above,also submit one copy of thisi form within 30 days of completion of well
6c.Borehole diameter: (in•) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:_� . (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
S~ f
lOc. For Water Suanly&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): AM.) 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 abandoned.
611 Inner casing/tubing length(if known):__(ft•) f
p t
6g.Screen length(if known):
Forth GW-30 North Carolina Department of Environment end Natural Resources-Division of Water Re�ouroes Revised August 2013