Watauga_Well Abandonment_20240529 (2)

FELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
( ► M 04�4 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
1 Well Contractor Name(or%N11 owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC WeliConlractor Certification Number 7b.Approximate volume of:water remaining in well(s): 1 D (gal.)
`YADKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company Na ie 1� D 1 Ttk aJ�
7c.Type of disinfectant used:
/ f� T_M
2.\Nell Construcfion Permit p:
List all applicable well constriction permits(i.e.UIC County,State, Variance,etc.)if brown D'Z
7d.Amount of disinfectant used:
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
rh
❑Ercothermal(Heating/Cooling Supply) M<esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ' ' y i?024
❑Industrial/Cornmercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cu ngs
❑Irri anion ❑ Specialty Grout - ❑ GravelbC�ih
Ntiri._Water Supply Well: &<entonite Slurry ❑Other(explain under
❑Monitoring ❑Recovery
uiiection Well: 7f.For each material selected above,provide amount of materials used:
`r,quifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier b ylV tD
❑Aquifer Test ❑Stormwater Drainage ��.Q7 46; stpA�
Experimental Technology ❑Subsidence Control. 7g,Provide a brief description of.the abandonment procedure:
❑Geotlief.RigT.(Qlosed'Lo0p) ❑Tracer t-�
❑Gegthgrmal.(Heating/Cooling Retgm. ❑Other(explain under 7 �� QC l ) C1A1t,:t� l/V IJ�"v
(� a� (ARM bAin 4 D
4.Date wells)abandoned: ( ' l /1 _( ASi -6A1 0 C /,1-rn l
51.Well location: rt' (,dJ
Ale.. -
Facility/Owner Name Facility ID9(ifapplicable) S.Certifi anion:
boa t 6 Wye Me
AS- r2
Physical Address,City,and Zip ignatvre ofCertified� o clot or Well Owner Date ..{.�
By signing this fonn, I hereby certify that the ivell(s) ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with I SA-1VCAC 02C-:0100 or 1C.0100 Well Construction Standards S
' and that a copy of this record has been provided to the tvell owner.
5b.,Latitude and longitude in degrees/minutes/seconds or decimal degrees: N
(ifsvcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
N V. 63/7 2 W You may use the back of this page to provide additional well site details or well O
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconsnvctionrecord(s)ifavailable. For multiple injection ornon-watersupplywells '
QNLY.widrthe some corstrvctiorr%abondonment,you can submit one form.
10a. For All }yells: Submit this form.wkhitt•.�h;days:of•completion of well
V ` O~ ( abandonment to the following:
Divisiou of Water Reso.ureesi Information Processing Unit,
6b.Total;Nell depth: v I (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniectiou Wells:. In addition to sending the form to the address in 10a
6c.Borchole'diameter: L2 .(in.) above,also submit one copy of this form within 30 days of completion of well r�y
abandonment to the following:. 1�
6d.:lVatcr level below ground surface: �J (ft.) Division of Water Resources,Underground Injection Control Program, .A
1636 Mail Service Center,Raleigh,NC 27699-1636
6es Outer casing length(if known): (ft,) 10c.For Water Supply&Injection Wells: In addition to sending the form to the TO
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): D (ft.) abandoned.
6g.-Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016