Union_Well Abandonment_20240429 (3)

ELL ABANDONMENT Rr'CO%l.trJ For Internal Use ONLY: j
This form can be used for single or multiple wells
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1.Well Contractor Info ation: WELL ABANDONMENT DETAILS
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� ' a ✓�Q� 7a:Number of wells being abandoned:
Well Contractor Name(or well owner Olersonally abandoning well on his/her property) For multiple' h jection or non-water supply wells ONLY with the same
construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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Y31 I. U�.Z FOR WATER SUPPLY WELLS ONLY: /�
Company Name / 7c.Type of disinfectant used: 1"D
2.Well Construction Permit#:
r List all applicable well permits(i.e.County,State,i'ariance,Injection,etc.)if known 7d.Amount of disinfectant used: f P) -
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) t ential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) oncrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each mater'al selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �pK.Pil
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: �1_ — '�•
❑Geothermal(Closed Loop) ❑Tracer❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
Sa.Well location:
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FaciI4vl(hvner Name Facility 1139(if applicable) 8•Certif ca '-D-J-7 y�
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Physical Address,City,and Zip, '�g+�— Signature of Certified Well C c[or or Well Owner Date
^��� By signing this f rat, 1 hereby certify that the ivell(s)ivas(were) abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.6200 Well Construction Standards
and t/tat a copy of this record has been prm ided to the well owner.
56.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:
3 Z rJ� N `^��� W You may use the back of this page to provide additional well site details or well
1 ! abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLBI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consinrction record(s)if available. For multiple injection or non-eater supply
wells ONLY with the same constnrctiadabandonntent,your can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well EN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: �Z (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10h.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: EXL/ (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 (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N (fL) 10c. For Water Supply&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 abandoned.
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft)
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Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013