Nash_Well Abandonment_20240710 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: ((���� WELL ABANDONMENT DETAILS
AdC,&I, i s r L;~^'IV 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
3 D(�o wells abandoned
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
bo I 0- FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type ofdisinfectantused: Ir k e(^'AIl AA-
2.Well Construction Permit#:
Lest all applicable well construction permas(.e.UIC',County.Srate. K—once,etc.)riftnown f
7d.Amount of disinfectant used: Ova
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 4T Neat Cement Grout Rr'Benton.. i;s nr Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete(rout' t ❑ nil Cute s
❑Irriaation ❑ Specialty o>Zt ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry I I I L 1 O �824 ❑Other(explain under 7g)
❑Monitoring ❑Recovery J J
Injection Well: 7E For each material sekcte gp+�vi_Wmoun of materials used:
❑Aquiter Recharge ❑Groundwater Remediation �`L_ 114i L -1 l bad
3Ofls t 2,
❑Aquifer Storage and Recovery ❑Salinity Barrier 11
❑Aquifer Test ❑Stormwater Drainage it)"a- ��/hnQ n T Z 111,135
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g) ,)eJfJ D171^64-d s 1'2 3112 -ZK
CAi.�s
4.Date well 7 s)abandoned: �� 2b2�( we'i` (a.-O-mi C04' G,t' '/r FT w 13,00 1
Sa.Well location: ^P/
3toab &0(n AuAnIAA 4 Z Fir 7-FT
1�. er l., kJ na 6,.c:e t n Wt 1 C k}Op Q.Ato'1 JR
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Iq fan a o lv Z-r
Physical Address,City,and Zip Sig of Certified -. . or or ell Owner Date
Nr� 3y 6Qo^1 By igning this form. I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with l 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:
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 ifnecessary.
CONSTRUCTION DETAILS OF WELLtSI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attoch well construction record(r)rfavailahle. For mubiple injection or non-water supply wet/s
piv/-y with the same construcnon'ahandonmem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6s.Well ID#: abandonment to the following:
z
Division of Water Resources,Information Processing Unit,
6b.Total well depth. 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-161-1
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: & (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: (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 Sanoh&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):NIP(ft) abandoned.
RECENEp
6g.Screen length(if known): �/� (ft)
JUN 2 4 2024
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-27.2016
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