Wake_Well Abandonment_20240731

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
.J d R Poole/ 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
( A wells abandoned:
d ( � �� C FOR WATER SUPPLY WELLS ONLY:"i rah pof, o
Company Name
� �� � 7c.Type of disinfectant used:
2.Well Construction Permit#: I
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)i#known
7d.Amount of disinfectant used: •
3.Well use(check well use):
Water Supply Well: 7e.Sealine materials used(check all that app v):
❑Agricultural Zesidential
nicipal/Public ❑ Neat Cement Grout Zentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation — ❑ Specialty Grout ❑ Gravel
Non-Water Supply Will... �� ! ; d ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: J��L _ � 7f.�each material sect�above,provide amount of materials used:
❑Ag uifer Recharge ❑Grou dater Remediation 6 sawl{—
y L
❑Aquifer Storage and�gpop8eg`"rff, I Anity Barrier r r
L/c
VKC; ,!V Cie
t b A
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,provide a brief description of the ab ndo ent procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 ) 64-y
'll4.Date well(s)abandoned: ` �-o ),3
5a.We I location:
J` n 0" Sat-Nae (5
Facility/Owner Name Facility iD9(if applicable) S.Certification:
Physical Address,City,and Zip Signatf of Certified Well Contractor or Well Owner Date
�k )0,dr`e' By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long 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 SUBMMAL INSTRUCTIONS
Attach well construction records)ifavoilable. For multiple injection or non-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
vv Pt1 t ny abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: ' A) 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:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known) (R•) iuc.ror water�umnv ac uttecuon ►revs: in auutlton to Senuing uic lul In 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
6L Inner casing/tubing length(if known): n a (ft.) abandoned.
6g.Screen length(if known): n Ql (ft.)
Form CTW-10 North Carolina Department of Fnvirnnmental Quality-Division of Water Resources Revised 2-22-2016