Wilson_Well Abandonment_20240710

WELL ABANDONMENT RECORD For lntcmalI w ONLY.
1.lticll(ontractor Information:�/ �/� �/�� p��W ABAtiD)NM NT S
JO.1� D f�1�1 ( c�oa�V• '1/ -For Geoprobet DPT or C-h(ud-Loop Geothermal Welk having the sum
Well Contractor Name for well owner Ixncxully abandoning well tin his her prtgvrty 1 well construction)'dcpth,only I (,\\-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:_A_._
NC well('(mtracuw Certification Numhc( 7b.Approximate volume of water remaining in wcll(s): (gal.)
FOR WATERSIJrrLY WELLStON1.1:
�l.trgvnv Natne _. �N�1�V%y ly 2
,\ 7c.Type of disinfectant used: l� ■■ r�
Well Construction Permit x:1'U1�
"r.rU.tntd"'M, aril,onxmr..-o.,::. - Eurtttm Y'.Mc.l ll Artoxn
ld..ltmtunt of Aisinfcctant used:_�
;.Well use Icbeck well user --
f Water Supply Nell: 7e.*waling materials used(check all that apph l-
\gncultural L;Municrpal Public G Ncat Cement Grout !irnkmite Chips or Pellets
(k,4,(hermal(heating Cooling Supply) '(esadmlial Water Supply(single) 0 Sand Cement Grout �i ihy Clay
L ilndustrial Commercial ORuidcnnal Water Supply(shared) )CComcrele(rtmat 0 %it Cutlinp
cairn•anon G Specialty Grout 0 Grav
Non-Water Suppiv Well: G 13etnonite Sfu f()thew c. ^i7t 71,1
0M,inahtrine JReeovers nY �I� 'L' _L�•
Injection Well: 7f.For each material wiccted attosc.prosidc amount ef(pNleri*is used--
GAquifer Rtxharge GGroundwater Remediation J V L 1 VA
GAquifer Storage and Recovery OSalinity Harrier kdrl:lrk;^tZ �•r�
ClAquifer Teat 13Stormwater Drainage �ft'.J it,
t Fxpcnmcntal Technology GSuhsWence Control
7g.Provide a brief description of the abandonment praredure:
::OLolhermal ICfoxd loop) LITracer AQ1 1 �1 o aC ,
DGetAhennal(Ileatin lCoolin Return) L]Chher tex lam under' Qg) V1��/�
w0v
J.Dale welllsl ahaudom'(:O V (�� Qv*-A - V\/I U,�V� 1 ip I/
.cur facthh fD#4aaMbrahka S.Cer(irica
0 P 1�1 ( WIC I IS
.-.. .,. ...•,,. , ���� .. +air cx Ncii Vwitcr
Rr.Yet;»nog thus loan. /hooch%rrnffir that the µrllr-s! N-as fnwrri abandoned in
c waay tart:f lacntntncannn no t pis 1 acetw ance with f;A:VCAC OX.alf)f)or'C".fr_flfl►F-ell Constrvt-tion.Gandardt
and that a trmt•of fhty rtrtortl hat her"rwowded to rite w+rl1 ovwner
Sb.Ladlude mod longitude In degreesladmuteVsecouds or decimal degrees:
(ifsvctf field.am(at'leng(s tufF.cientl t y 4-Site diagrarn or additional well detads:
You may use the back of this page to provide additional well site details or we!I
1 y abar"minent details. You may also attach additional pages tf neceman.
CONSTRU( I N)N DETAILS Ot WELL(S)BEING ARANDONED SUBMITTAL INSTRI'(I IONS
.!Quc6xclLuA+v'ruiuMRY'O!"d/.(ItJ4i'AlIt1hl('. FIxRlalhOh'tM('ta(MfJ!'ROR-xYlF('Iltpttivnflll
MVLY With tke.came(carttrn<'hanahartdMmrnt.roa can saboiaonein xi l0-a. Fur All Wells: Submit this font �sttlun 30 davc of completion of well
Wen IDN. abandonment to the foliowmg.
4
'1
— Division of Water Resources.Information Processing I_nil.
6b,Taint We#depth: V (R.) 1617 Mall Service('enter,Raleigh.*('27b99-1617
lob.For Inicetion Welh- In addition to.ending the form to the a.ldre,s in I(kn
6c.Bareltote diameter; 21 iin.) above, also sutrmit one copy of this form within 30 days of completion of wolf
Z� abandonment to the following:
6d.%ater level below ground surface: ./ Ift) Division of Water Rewurces,Underground injection Control Program.
1636 Mail Service Center.Rak4gh.NC 2709-1616
be.Outer casing length(if known): (K.) loc.For Water Sutmty dt inlectioa Wells: In addium to sending the torn to the
address(cts)abuic,alai submit one copy of this firm within 30 days;of completion
of well abandonment to the county health department of the county where
6f.inner cosine/tubing length fif known): (ft) Abandoned.
6g,Screen length(if knnvvn1: (ft.)
Form(Ica-30 North Carolina Decpwttrrant of Envinminental Qtwlns-Diviswn of stater Rcs"rccs Rc%iscd 2-22.201(i