HomeMy WebLinkAboutMoore_Well Abandonment_20240610 (3) WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Co or I ati WELL ABANDONMENT DETAILS
Si W&415A 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
1 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
1 5 e-L f wells abandoned:
NC Well Contractor CertificationlNumber 7b.Approximate volume of water remaining in well(s): (gal.)
Morgan well & Pump, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name `�( �q /l/'�'� &_ 7c.Type of disinfectant used: l Z D Z
2.Well Construction Permit#:
—1 l J
List all applicable well construction permits(i.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 ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) El Sand Cem" �i :+p Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout` ` ❑ Drill Cuttings
❑Irri ation ❑ Specialty Groud U N 1 0 2024 ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery WhornwAxri P,cr ws� rq Urt
Injection Well: 7f.For each materialOM"Q11mle,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the aband nment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
Sa elllocago
Facili.tykOwner Name Facility ID#(if applicable) S.Certification:
�,�..
C�) -� qU A16 T,IbVY 705
PhysicalAddress,,- aCity,and Zip of Certified Well Contractor or Well Owner Date
/t X — 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same consiructionlabandonment,you can submit one form.
lOs. 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/ (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: 14 (ft.) Division of Water Resources,Underground Injection Control Program,
/� 1636 Mail Service Center,Raleigh,NC 27699-1636
V
6e.Outer casing length(if known): ' (ft.) 10c.For Water Supply&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
6LInner casing/tubing length(if known): (ft.) abandoned
6g.Screen length(if known): (ft.)