Watauga_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.11—'-ellll Contractor Information: NVELL ABANDONMENT DETAILS �c
f tM�Tt'1 ( �`e 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well ContractorNarnkfor well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
t
NC we1l:6ontr'cctorCertification Number 7b.Approximate volume of water remaining in well(s):��(gal-)
`YADK[N WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company?4aiiie
7c.Type of disinfectant used:
2.Well Construction Pcvmit N: V6`�' S$
List all applicable hell constnrction permits(i.e.U1C.County,State,Variance,etc.)if brown
7d.Amount of disinfectant used: Qj�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ BentoniteChipsor.Pellets.
❑Geothermal(Heating/Cooling Supply) lVesidential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential WaterSupply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Iri ation ❑ S ecialty Grout _ ❑ Gravel
Ntiri-Water Supply Well:
entonite Slurry '°r ❑ Other(explain and�.7 ,
❑Monitoring ❑Recovery ` •�..,:'_'.: -
liiicetion Well: 711 For each material selected above,provide amount ormaterials used:
i',quifer Recharge ❑Groundwater Remediation } ' `� U
�1
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 120D Is SA .
❑Experimental Technology ❑Subsidence Control
e al.(Closed'Lo p) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
OGe`4tK �gio
OG�gttl„ina(_(Heatittg/Cooli rn:.ng Retu ❑Other(explain under 7g) e i4 tatnij t A'AK �3 N
V ilk
d:Date well(s)abandoned: cJ"e`t914
SiltRAtJ I
5a.Well location:
fir z
Facility/OivnerName Facility lD#(ifapplicable) 8.Certif ation:
Physical Address,City.and Zip
aturc otCertiBed Well n r or ell v r Date
By signing this form, I hereby certify that the ivell(s) was (were) abandoned in -s
Counq• Parcel Identification No.(PIN) accordance with 15A•NCAC 01C-.0100 or 1C.0200 Well Construction S[andards C
' Sb.,Latitudeand longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if'vvPlll field,one Iat/long is sufficient) 9.Site diagram or additioual well details:
JKI ds p�� N �� 1 `W You may use the back of this page to provide additional well site details or well
t -- abandonment details. You may also attach additional pages if necessary. �w
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED 7—
Altac/rtrellcatstnrctionrecord(s)ifovailable. For multiple injection or ran-watersupp/ SUBMITTAL INSTRUCTIONS
ywells
ONLYwith the same coa.stnrctioitlabandomnent,ydu can submit one form. }hL
10a. For All Wells: -Submit this form.vrkhitr.,N!!days..of•completion of well
f'" ++ abandonment to the following:
Division of Water Reso.urcesi Information Processing Unit, J
1617 Mail Service Center,Raleigh,NC 27699-1617 IN
6b.Total,
tivell depth: (ft.) g
10b.For Iuiection Wells:. In addition to sending the form to the address in 10a
6c.Borehole diameter: V (1n,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:.
6d.!1Water•l.evel below ground surface: (ft,) Division of Water Resources,Underground Injection Control Program,
j� 1636 Mail Service Center,Raleigh,NC 27699-1636
6q.Outer casing length(if known): (jt) 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.
6g_Screen length(if known): `/ (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016