Pender_Well Abandonment_20240710

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractgr Information: WELL ABANDONMENT DETAILS
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�T CL,�— 7s.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
Awells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in wdl(s):
SO Ur V�'IlA l�n �- ( J ,S FOR WATER SUPPLY WELLS ONLY:
Company Name
�� _� 3b _ 7c.Type of disinfectant asr°d: S r 1 en e—_
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC.CPunty.State.Variance,etc.)ifknow Q
►J Cw r 2 !r�rz itlE.nt wee(i J 7d.Amount of disinfectant used:
3.Well use(check well use): 0Id iv it perpt ut7 lGq w
Water Supply Well: 1 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout JkBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑Sand Cement Gam. `' "` ,1� /E Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout y�p 11 Cuttings
❑lrri ation ❑Specialty Grout JUL 1 0 W4❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery If�S:f%.."` r-tY'd.`",��J.*A
Injection Well: 7E For each material amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery []Salinity Barrier SJ t
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ^ ` I n
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) IJU Vl A Vu M% P Q$yred We tk \ .
G.��.Zy (,Mo ,n�W . Added -ben nr k cl o (AL(
4.Date well(s)abandoned:
Jug[( i1,1 c,S
5a.Well location:
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Facility/Owner Name Facility 113#(if applicable) 8.Certification:
3 Ac, 3 Gta7•��
Physical Address,City, Zip I
7 J ?? Si of Cenifi Well Contractor or Well Owner Date
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�tx�te if 3`q3_qq `�6 By signing this Jorm, 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
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/tong is sufficient) 9.Site diagram or additional well details:
21J O •� t ` rt N 7"7 d Y0 t -7 1 t W You may use the back of this page to provide additional well site details or well
t abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Anach well construction record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construetionlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:J On KNOW abandonment to the following:
p Division of Water Resources,Information Processing Unit,
6b.Total well depth: p (R.) 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: (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: (tt.) 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 Supply&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
r_ of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): lL (ft.) abandoned.
6g.Screen length(if known): (ft.)