Ashe_Well Abandonment_20240529

WELL ABANDONMENT RECORD For internal Use ONLY:
1.,(Well Contractor Information: WELL ABANDONMENT DETAILS
t y' , yn"\cot 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
WJ Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW�O is neede dicate TOTAL NUMBER of
wells abandoned: i/
NC Well'•Cdhfiac'torCertiScation Number 7b.Approximate volume of-water remaining in well(s):
''YADKI'N WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Comptiy Naiile
I q 15 10 7c.Type of disinfectant used: Tr/
2.Well Construction Permit 9:
Lis(all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if!mown /
7d.Amount of disinfectant used: - 3 tr, 0 —
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Gcothermal(Heating/Cooling Supply) *esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay, : r
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑(n-i ation ❑ Specialty Grout - ❑ Gravel MAY ry r!�24
Nor.-1\'ater Supply Well: Bentonite Slurry `� ��
❑ Other(explain under 7g)
❑Monitoring ❑Recovery IG";;•,.. '
ulirctl Olt Well:
7f.F
or each material selected above,provide amount of mate�inlsssed
`aquifer Recharge ❑Grotindwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier —
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothei.r�l .(Closed'Loop) ❑Tracer
y
pGggt�.rma(.(HeainglCoolitt _Return: ❑Other(explain under7g) py�^P �d�7 V/!1_Rjp
d:Date wcll(s)abandoned:
,9rr�
5a.Well location:-
Faeih OUivner Name Facility iD9(if applicable) 8.Certification: /I
43 -1 27 w r D T►R I 3-f we as I
Physical Address,City,and Zip, cR 41 6 C1L/ Signature cf Certified Well Contractor 6—rWell Owner Date
���� By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A•NCAC 01C-:0100 or 1C.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:
(ifwFll field,one[atlIong is sufficient) 2 9.Site diagram or additioual well details:
3 G q 1 f �7 7 N U 1 1 1 7 J '� 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 DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Amoclnrellconstnretionrecord(s)ifovailoble. Fa;multipleinjectionorna,a-matersupplyu-elts
OtVLYivitlydFe some co,rrtrxrctioniabandonment•ydu can submit one form. _
10a. For All Wells: -Submit this form.wkhiR,,N,,drays..of•completion of well
l 'y ' abandonment to the following:
Division of Water Reso.urcesi Information Processing Unit,
6b.Total ell depth: 30
V (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Job.For Injectiou 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: .2 d (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6cy Outer casing length(if known): 3 o (ft.) loc.For Water Supply&Infection 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.
6g.-Screen length(if known):
Fotln GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016