Union_Well Abandonment_20240610

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Infor lion: WELL ABANDONMENT DETAILS
7a.Number of wells being abandoned: /
Well Contractor Name(or well owner perso ly abandoning well on his/her property) Far multiple injection or non-water suppy, wells ONLY with the same
L+ ,S,;� (— construction abandonment,you can submit one form.
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): EL � (gal.)
i�-3 lJW'P—a ( L�1 FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: r , , 79
2.Well Construction Permit#: 4r�b J)List all applicable well permits(i.e.County,State,I ariance,Injection,etc.)ifknown 7d.Amount of disinfectant used- Z Ga V""+
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) nttal Water Supply(single) ❑ Sand Cement Grout ❑•Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) L;-Ir n rete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation �aQs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1 Wd-.. d
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) � '
4.Date well(s)abandoned:
;a.. (Well location; nQ y���/�/tt�' / {�
../"1✓_,d ✓ ).j) f).Q�J�'r, 'Q 4 M/ uINl:xrir4.er1 f-��lf[i�'yea
FaciliY/Owne— rName T / Facility ID#(ifapplicable) g•Certifl F�
Physical Address,City,and Zip Signa[ ofCertifie ell—Contractor or Well Owner Date
u n t,e-) 0Z , Z3�- 0 0' B signing this form, I hereby verb that the wells was
y gn g f y fy () (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well turner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
3r)^ N '� L_y L1 O - You may use the back of this page to provide additional well site details or well
O 1 t� 1 W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach well construction record(s)if available. For multiple injection or non-waler supply
wells ONLY trith 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:
Q Division of Water Resources,Information Processing Unit,
6b.Total well depth: / (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
L' above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: T (in.) abandonment to the following:
6d.Water level below ground surface - (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): IV lzt (ft.) 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
F.Inner casing/tubing length(if knows): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013