Wake_Well Abandonment_20240507

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WELL ABANDONMENT RECORD For Internal Use ONLY: I
This form can be used for single or multiple wells
1 ell Contractor I ormation:
6 0 tui WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned:
° For multiple injection or non-water supply wells ONLY with the sane
3 Well Co ctor ame4(or well owner personally abandoning well on his/her property) construction/abandonment,you can submit one form.
�� l 7b.Approximate volume of water rL niaining in well(s): (gal.)
NC Well Contractrf Certification Numb
inytL ssl7� /t A FOR WATER SUPPLY WELLS ONLY: , k
/�l t - ��""" 1 �l
Company Name 7c.Type of disinfectant used:
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2.Well Construction Permit#:
List all applicable well permits(i.e.Cotrnry,Scare,Variance,Injection•etc)if known 111 i4---- .
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:
7e.Sealing materials used(check all that ap y)•
❑Municipal/Public 0 Neat Cement Grout entonite Chips
or Pellets
❑Agricultural � D Clay
Grout 0 Drill Cuttings
❑Industrial/Commercial t7Residential Water Supply(shared) 0 Concrete _
0 Specialty Grout 0 Gravel
Obligation 0 Other(explain under 7 )
N n-Water Supply Well: 0 Bentonite Slurry ( P g
onitoring ❑Recovery
7f.For each material selected above,provide amount of materials used:
Aquion Well: (c j j, t/►
. ❑Aquifer Recharge ❑Groundwater Remediation �v( ,�jjt�d 111 ie �t P"F
❑Aquifer Storage arid Recovery • ❑Salinity Barrier 2- pis, woke
❑Aquifer Test ❑Stormwater Drainage 1;
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description Z,oof the abandonmentc procedure:
OTracer t— /vi to b�/t& Cii fr (, vu., 9ls
❑Geothermal(Closed Loop) S!,t rA
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) f - wet/ 4G 0`4 %,
! ir , G"D e /#/sim 41,1e, T
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4.Date well(s)abandoned: l I e 3 -t hN I fe/V'it- i-.241 02/�(e- chi, f - Y,puiiii, _ ..,
Sa. "b tt_�r °t� L/ �IA
1 r MAY t► i 202
L,e S.Certif lion:
Facility/Owner Name Facility 1D/I(if aapplicable)
Pi �� M 1rY ..-z-•ix.^i "'.r;..,svy ;e: , .
4101 1041 ell ®hu d, �U e4111 -��f ZY,
ore of rtified We Contractor or Well Owner Date
Physical Address, rty,and Zip
0of ce 11StIR I 1223 By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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: i9.Site diagram or additional well details:
(ifwe115eld,one lat/long is sufficient) Q
Jg� �„ �i N (� / You may use the back of this page to provide additional well site details or well
3 .y! "11'�S— bI W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLY with the some construction/abandonment.,M 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#: l rt�,A),�
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC.27699.1617
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6b.Total well depth: 40 CA (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
3111
1 f above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in•) abandonment to the following: \•
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.z 1 Division of Water Resources,Underground Injection Control Program,
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6d.Water level below ground surface: I •l (ft.)- • 1636 Mail Service Center,Raleigh,NC 27699.1636
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1.t. IOc.For Water Slimily&Iniection Wells: In addition to sending the form to
6e Outer casing length(if known): 1 ' (ft.) 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
A� where abandoned. � ,
6f.Inner casing/tubing length(if known): '`r 14- (ft•) ; ,
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1 ! ;
6g.Screen length(if known): I (ft.) 1
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013