Ashe_Well Abandonment_20240814

WELL ABANDONMENT RECORD F„iinter❑al Use ONLY.
1.Well Contractor Information: WELL
WELL ABANDONMENT DEILQU
-16.e r� S 1 G7T 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on bis-her property) well construction/depth,only t GW30 is needed. Indicate TOTAL NUMBLR of
2 7 p 1 ` /k wells abandoned:
NC Well Contractor Certification Number �1 7b.Approximate volume of water remaining in well(s): isd (gal.)
U&L i KC s� r nt- `f�"l t o n � m D &f U i e LLC FOR WATER SUPPLY WELLS ONLY:
Company Name Q�Q 7c.'Type of disinfectant
2.Well Construction Permit#: Q
List all applicable evil constn4ctlon permits ii.e UIC,Cormn.Sarre, Variance,etc.j rjknown /_
7d.Amount of disinfectant used: il.p O Z
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public D Neat Cement Grout �ntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Vre—sidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
Olndustriat/Cotnmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Olrri ation D Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ElOther(explain under 7g)
❑Monitoring []Recover-,.-
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
0Aqui1'er Storage and Recovery ❑Salinity Barrier 3 5 6S►aS C'1,:� _
❑Aquifer Test ❑Stonnwater Drainage I has i or4laad
IDExperimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g,Provide a brief description of the abandonment procedure:
I 11
DGeothennal(I{eatin Coolin Return) ❑Other(explainunder7 ChLnr.'actF'C.d JAlf. ChId s4en SCfr-'en
4.Date well(s)abandoned: 7- S Qa�7 (l,J-fw q r\d ( CO 'CIYI Q S
in.Well location: q n_ ,.., b .....�..�...• +; 1.�;,..,
1Dc6o c al j hgu } l�t�l J U G 1 4 2024
Facilitv,Owner Name Facility M#(if applicable) S.Certltteation:
F(ee� ,., w; . .
_$b7 New l2t �nrr t"3en„j SrJy Wao Ir,:.,:;._
�7� , �
Physical �-
Address,City.and Zip g Signature of Certified Well Contractor or Well Owner Date
a7 5` 1�7 �p 13.1,signing this•/orm, I hereby,certljv that the well(s) was(were) abandoned in
C ounth Parcel Identification No.(PIN) accordance trlth 15A NCAC OX.0100 or 2C.0200 Well Consititction Standards
Sb.Latitude and longitude In degrees/nnlnutes)seconds or decimal degrees: curd that a copy of this record Ms been provided to the well owner.
(if Weil field,one lavlong 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 mall also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)B 1NG ABANDONFr) SUBb1ITT i. vSTR ; .TI
Attach well constniction record(s)ifavailable. Formidtiple Injection or non-w y w atersupplells
XJ
ONLY with the slime construction abandonment,i vit can submit one form,
IOn. For All Wells: Submit this form within 30 Jays of completion of well
6a.Well ID#: abandonment to the following:
t Division of Water Resources,Information Processing Unit,
6b.Total well depth: $3 (ft.) 1617 Mall Service Center,Raleigh,NC 27699-1617
I t 101b.For Infection Wells: Ir addition to sending the form to the address in 10a
6c.Borehole diameter: to (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: 10 —(ft.) Division of Water Resources,Underground Injection Control Program,
l ' 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N A (ft.) 10c.For Water Suonly&Injectlon Wells: In addition to sending the form 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
6f.Inner casing/tubing length(If known):_AJ_A_(ft.) abandoned.
6g.Screen length(If known): 1NJ Pf (ft.)
Form GW-3O North Carolina Department of Environmental Quality-Division of Water Resaurces ke iwd 2-22-2016