Caswell_Well Abandonment_20240731

WELL ABANDONMENT RECORD —
For Internal Use ONLY:
I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
-3—c1/4 re. A) f
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner pe onally abandoning well on his/her property) well construction/depth,only 1 G1V-30 is needed. Indicate TOTAL NUMBER of
Z 77 C wells abandoned:
NC Wet Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gaL)
q UG D l/ .LAG ' FOR WATER SUPPLY WELLS ONLY:
Compa Name
7c.Type of disinfectant used: HT� e/0 'le
2.Well Construction Permit 4: 339 5
List all applicable well construction permits(i.e.UIC Count;Slate,Variance,etc.)iflbrown ?
7d.Amount of disinfectant used: /, 4e
3.Well use(check well use): — J
WaterWater Supply Well:
cultural 7e.Sealing materials used(check all that apply):
❑Municipal/Public 0 Neat Cement Grout
❑Geothermal ❑Bcntonitc Chips or Pellets
(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout
❑IndustriallCommeroial ❑Dry Clay
❑Residential Water Supply(shared) Concrete Grout 0 Drill Cuttings
❑Irrigation
Non-Water Supply Well: 0 Specialty Grout 0 Gravel
❑Monitoring 0 Bentonitc Slurry ❑Other(explain under 7g)
❑Recovery
Injection Well:
7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /'
❑Aquifer Storage and Recovery ❑Salinity Barrier `�et►'1 P�4-
DAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) "2-:vicr/ee/ -frim PC
J I (�iW/1
3.I i eenistn4 etir 1J iced. .',n t„14`44t 4.Date well(s)abandoned: 07/ 2 tf/ a/ C`J
Se.Well location: d/J t Cep,on t�1 t1 `
-Sraetcloy) Prerns )L 3Z0'.
Facility/Owner Name Facilityd Mr(� applicable) a Certification:
3S6 Bowlers Inferrc“..0 P-•. 304.;:�7 Ur.?
enue 2 .idsuilie .t1C, 97320 y+:.
Physical Address,City,and Zip
� Welt-Conh� �,Z y/
Igrnture of c etor ar W:ll wner
Caswell
Bysigning this fonn,I hereby ceriI that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN)
accordance with 15A NCAC 02C 0109 or 2C.0200 Well Constntetion Standards
56.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 latifong 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(S)BEING ABANDONED
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the same cnnstruction/abandnnment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well UM: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: ?S (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
/' lab.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: C'� (in.) above,also submit one copy of thin form within 30 days of completion of well
^`` abandonment to the following:
6d.Water level below ground surface: L/V (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniectior Wells: In addition to sending the form to the
6e.Outer casing length(if known): ((L)
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): (ft,) abandoned.
6g.Screen length(if known): (ft.)