New Hanover_Well Abandonment_20240507

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT;DETAILS
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1'()L-Q 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name r well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
44 c✓ A wells abandoned: iI
NC Well Contractor Certification Number 7b-Approximate volume of water remaining in well(s): 71 5 (gal.)
SOU 11❑Y QOJCeA E ✓.Q, "J 1 CQ S I .LC FOR WATER SUPPLY,WELLS ONLY: _
Company Name l
7c.Type of disinfectant Used: Z)3
2.Well Construction Permit#:OS W?W P'2J -C1)4-5 '
1.
List all applicable well constriction pennits(i.e.UIC,County,State,Variance,etc.)ifknowm (�1�, �
L * 7d-Amount of disinfectant used:JT(�('(`{✓�Q_
3.Well use(check well use): Re rk to P te-A W e 1( ?elf"r r-J
Water Supply Well: ` 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout ArBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
_ Non-Water Supply Well: 17 Bentonite Shiny ❑Other(explain under 7g)
❑Monitoring ❑Recovery
:Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �Ci 1 S aen i.�, �' ({p
❑Aquifer Storage and Recovery ❑Salinity Barrier J I t/
❑Aquifer Test ❑StormwaterDrainage 1 '
t.
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under7g) CAIlOri)A0-1-e4 (Pell , C.-U+Cf-e- CQS1"j CL+ Q(WLM
1� r� �y Level . stowIY oa i.r___cln(es Un+tN well
4.Date well(s)abandoned: I .2)_.2_ '�
was l l 4-0 4,ra. p� r �. •4.._r lt 1
5a.Well location: I MAY V 7 2024
131 a t (/).S 4 DIl� Vic; �w
Facili. b ner Nang Facility ID#(if applicable) S.Certification: f� itYf;i ri=i •f ^:?j URA
J c �:�" cry
Physical Address, and Zip Signature of Certified Well Contracor or Well Owner Date
A(() ,, 2 C�(p4-b r 1
Qh D J�► V�� �� �" By signing this form,1 hereby;certify that the well(s)was (were)abandoned in
County Parcel Identification No.(P1N;9 O D accordance with 1 SA NCAC 02,C 10100 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: i
(if well field,one lat/long is sufficient) 9.Site diagram or additional*ell details:
2,i.!0 i! I I I� N e 1.(i 1 poll W You may use the back of this page to provide additional well site details or well
J 1 l�0 1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
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6b.Total well depth: 5 ` (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Injection Wells: In addition to sending the form to the address in 10a
6c.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: (ft.) Division of Water Resources;Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Injection'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
6f.Inner casing/tubing length(if known): - (ft.) abandoned. i
6g.Screen length(if known): (ft.) '