Nash_Well Abandonment_20240710

WELL ABANDONMENT RECORD For internal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
5k1C.b0AJ 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 I GW-30 is needed Indicate TOTAL NUMBER of
-�h wells abandoned-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in wcll(s): (gal.)
SA`t a—:RAI�P FOR WATER SUPPLY WELLS ONLY:
Company Name
' ��� 7c.Type of disinfectant used: rA�QCT�sl�
2-Well Construction Permit#:
List all appircohle well construction permits(i.e.U1C.County.State, Variance,etc.)ijlmown
7d.Amount of disinfectant used: � ( ✓� �r 7
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public p'fJeat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eKsidential Water Supply(single) ❑Sand Cement Gro t..;`r r• • t` ,Cj y
❑Industrial)Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ` • 01THMCuttings
❑irrittation ❑Specialty Grout JUL 1 U 21P/1➢ravel
Non-Wafer Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery Ijr`o:i'tc'rt1 "r3�tlatG'
injection Well: 7E For each matenal selectejp�de amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation i .1�, CJZ�-Y� y 1lit�
❑Aquifer Storage and Recovery ❑Salinity Barrier 1� _-'-71
❑Aquifer Test ❑StormwaterDrainage ��� �' 1 IOa� �57dA�S
❑Experimermtal Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 1 11 C lar;n kd 6 U 23L262 Y
L J .V-r Q�M.,id at CetsiliK [-to r_Oe]J
4.Date well(s)abandoned: was—qm y �y CIS S�bw{ ,M��� � P�.t��✓
Sa.Well location:
I Pr k -1FT X Z FT Y rd C.Caa4 Caif po wa)
�n _ G3i��ln 1'7y N a J
Facility/Owner Name v _ Facility ID#(if applicable) 8.Cer ificatioo:
_
Physical Address,City,and Zip ture ofccrtified We Con ar Well Owner Date
signing this form. I hereby cent that the well(s) was(were) abandoned in
Couny Parcel Identification No.(Pil ) 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 degreeslrninutes/seconds or decimal degrees:
(ifwell field,one latAong 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(Si BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atiachweli construction record(s)rfavailab/e. For multiple injection or non-watersupplyuells
ONLY w-ith/he some construction abandonment,you can submit ore farm.
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 WOW: In addition to sending the form to the address in l0a
be-Rorehole diameter:Z_(in.) above,also submit one copy of this form within 30 days of completion of well
2 abandonment to the following:
6d.Water level below ground surface: J*25 (ft.) Division of Water Resources.Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
be.Outer casing length(if known): -3 (ft.) 10c.For Water Suomh&infection 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
6E inner casing/tubing length(if known): (n,) abandoned
gECENM
6g.Screen length(if known): (R)
JUN 2 4 2G24
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
NC DEQ/DWR
Central Office