Moore_Well Abandonment_20240610 (2)

WELL ABANDONMENT RECORD For Internal Uae ONLY:
1.V1re l tracto I formati WELL ABANDONMENT DETAILS
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
61L� ((�1 _ CI wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
j 7
Company Name H g b b 4 7c.Type of disinfectant used: I v
2.Well Construction Permit#:
List all applicable well construction permits(7.e.UIC,County State. Variance,etc.)if known �C)(`�P L
7d.Amount of disinfectant used: `{ {, V� \ 1(�_
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
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout-. s Clay
4.. �l�� y
❑Industria/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout J U N 1 U 424❑Gravel
Non-Water Supply Well: ❑Bentonite Sl ❑ er(explain under 7g)
❑Monitoring ❑Recovery 'I`Kx''o'Mryryg���t,,t��`,,�r•�"q liR�
Injection Well: 7f.For each material seleef�d'alsb�e Rovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation � a SS❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the allandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ` rr !! �
❑Geothermal(Heating/CoolingRetum) ❑Other(explain under 7 rr vX` l/l J G L
4.Date well(s)abandoned: _
5a.Well location: / "_
�'YYl i kV, 'Q n l_(JY�
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
9 3144 .UC f 'W 10 5 cayit sff'eO
Physical Address,City,and Zip Si of Certified Well Contractor or Well Owner Date /
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
N 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 WELLlS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLYwith the same constructionlabandonment,you can submit oneform. 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: S 00 1617 Mail Service Center,Raleigh,NC 27699-1617
/- 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: l� (�,) 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: /V (ft.) 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 Sunuly&Iniection 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
61.Inner casing/tubing length(if known): --'—'1 A) abandoned
6g.Screen length(if known): (ft.)
-- _ _ _. _ ..._ ... ... ..•..•.•.. .nor'•_-r'""'-_-_ D...:e..i 7_77_')A11.