Moore_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY:
1. WELL ABANDONMENT DETAILS
t 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY: 7
Company Name g C1 O 6 Z !S
7c.Type of disinfectant used:
2.Well Construction Permit#: —
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.)ifknown
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 t Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Gro �- UpiZClay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout I",`�—'L..t V x 1. - Cuttings
❑Irri ation ❑ Specialty Grout JUN 1 p 242$ Gravel
Non-Water Supply Well: ❑ Bentonite Slung Other(explain under 7g)
❑Monitoring ❑Recovery W AOrm"en
Injection Well: 7f.For each material select vide ammo�unt of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 15
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the ab ndonment procedure:
❑Geothermal(Closed Loop) ❑Tracer /" ( A 'I`
y
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 � A, `�1(
4.Date well(s)abandoned: icL L
Sa. ell location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
gz�7 /V(-' if'Wu maytre Sfr,ln1t 'Z Z y
Physical Address,City,and Zip � S re ertified Well Contractor or Well Owner Date
G lam' ly— (' �� �� 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavai/able.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
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: t�v (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: p K. 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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): (g,) abandoned.
6g.Screen length(if known): ! v (ft.)