Union_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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Inf r0on: S WELL ABANDONMENT DETAILS '
0 �J (J 7a.Number of wells being abandoned:
Well Contractor Name r well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
consiructionlabandonmeni,you can submit one form.
Well Contractor Certification NIher 7b.Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 4 I t4
2.Well ConstructioPermit#: "�
List all applicable well;rmits(i.e.Cowry,State,Variance,Injection,etc.)if known
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply)-
❑Agricultural QMunicipal/Public ❑Neat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑ Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation - - - '" r" ❑ Specialty Grout ❑Gravel
Non-Water Supp' Well. t.J L_ ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ORtxovery
Injection Well: 29 7E For each material selected above,provide am unt of materials used:
❑Aquifer Recharge Y' a r r ❑ 46,1 fGw4ndwater Remediation n
❑Aquifer StoragOttnQ k� •��x,s�i�,� �7Salinity Barrier
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❑Aquifer Test QStotmwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) QTracer 1 he I
K��eQGeothermal(Hearin Cooling Return) QOther(explain under 7g)
4.Date well(s)abandoned: 'O '
5a.Well location:
Gordan i R-cQ
Facility/Owner Name Facility M#(if applicable) &- rtifiea n:
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Physical Address,City,and Zip Q true fC 'fied We l Contractor or Well Owner Date«
�n t^ iJ�V` By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude In degrees/mina[es/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one latAons is sufficient) 9.Site diagram or additional well details:
t �3��7 N �U ( � f�(// W You may use the back of this page to provide additional well site details or well
C(/ abandonment details_ You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEINC ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-waier supply
wells ONLY with the same constructionlabondonment,you can submit oneform. 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 (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) 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
g � 10c.For Water Supply&Infection We lls: In addition to sending the form to
6e.Outer casing length(.if known): ft) the address es above, also submit one address(es) copy of this form within 30 days of
completion of well abandonment to the county health department of the county
Inner casing/tubing length(if known): (ft.) where abandoned.t� t( �{ —
6f.
6g.Screen length(if known): '�tM (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013