Union_Well Abandonment_20240903

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well o tractor Info anon: ,/ WELL ABANDONMENT DETAILS
I SI�/ 11 7a.Number of wells being abandoned: /
Well Contractor Name(or well owner osonally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
LV5 construction abandonment,you can submit one form. /) �7
N Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): `7 ` (gal.)
L. ilrA\s\k1,j \jA) ai`rs) FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 1-7 TN
l}
2.Well Construction Permit#: a 1 3 1
t List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known / 7
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) LefteSSential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) '��concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7 L. PeaLf
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the aband nment procedure:
OGeothermal(Closed Loop) ❑Tracer rr ` i '?
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) C-k�a Ir`i/�� U�� J (-4,��
-r" ri 11t.4 e i/Pose to .,
4.Date well(s)abandoned: V I ' 't/2‘1
5a.Well location: t
/Facility/Owwner Name 1 J r Faci_lityyIID_#(if applicable) 8•Certific (� /
T 5I O isl i/4.hOi 1X V—+O X�V 1V NC' 7/Z Z/ Z
Physical Address,City,and Zip SiQojIdWellCOncrOrWellOwncr Date /
eA el t or' 057()90 O 36 By signing this form, I 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 ladlong is sufficient) 9.Site diagram or additional well details:
3y- 9/6 7 Z N 'o '7&v1 You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)f available. For multiple injection or non-water supply
wells ONLY with the same conrtructiorrahanuforrmenr,you can submit one form. I(ls. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: he hcz, abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ff.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection 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: Z y (in.) abandonment to the following:
6d.Water level below ground surface: / U (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): n'� (f�) 10c. For Water Supply& Iniection 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 abandoned.
6f.Inner casing/tubing length(if known): N (ft.)
6g.Screen length(if known): , (ft)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised Arms 7011