Davidson_Well Abandonment_20240918

LL ABANDONMENT RECORD
For Internal Use ONLY:
I.Well CC'on tractor Information: WELL ABANDONMENT DETAILS '
!' •• • 'm y Spanes LlIvie 7a.For Geoprobe/DPT or Closcd-L lop Geothermal Wells having the same
Well Contractor Name(jr well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is.needed. Indicate TOTAL NUMBER of
`,. wells abandoned: �. .
'�o1.3a (� .
•NC Well; oittrartor Certification Number 7b.Approximate volume of water remaining in well(s): • 1.50 (gal.)
'Y DKI°N WELL COMPANY INC. •
FOR WATER SUPPLY WELLS ONLY: t
CampanYNaiiie :
��2 . 7c.Type of disinfectant used: "?oA % C%IOC(�Z
2.Well Construction Permit#: `a'L'916 - • T•
List all•applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if Lwow?: _
7d.Amount of disinfectant used: I `'jpes
3.Well use(check well use): '
•
•
Water Supply Well: . • 7e.Sealing materials used.(check all that apply): .4-1
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay ' ' 0
❑Industrial/Commercial •• ❑Residential Water Supply(shared) i Concrete Grout ❑ Drill Cuttings 'S
❑Irrigation 0 Specialty Grout . _ 0 Gravel . 0
Nor.-Water Supply Well:
0 Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery •
•Liiection Well: 7f.For each material selected above,provide amount of materials used:
r::.tkquifer Recharge ❑Groundwater Remediation �] /�� '� m.••-
• ❑Aquifer Storage and Recovery • ❑Salinity Barrier •i Cond., �� "" �� �'"' Y �•,�s� Gb
❑Aquifer Test - ❑StormwaterDrainage • - • 'SEP 1 Q 2014
❑Experimental Technology ❑Subsidence Control• • =••"
• 7g.Provide a brief description of the abandonment,profeduv .. ,�r�rr, q u :_ t
❑Geatliermal(Cfosed'Lgdp) OTracer p . ... . . n;,,,r.. i,,.,_ i r ;r,gu-c1 9
• OGogth.�ttpa(,.(Hea ing/Coolittg.Retirm), ❑Other(explain under 7g) R1n6'lei (t .44:-.• ..�'\Or 10, iLQ, .�(6Q l\ GuNCes420C3 l.�
1 1 '-i..•.. L v a S.
~ '�: ' Pall ypL ee e- AIN'T` •4 /L(�' 4/0•
4:Date well(s) •abandoned: IO^�) , .
Sa.Well location: •
-7-•
•
•
•
Frr�qss.k ')A a)AL I'Nlbertic. • ' . ,
Facility/OivnerName pRaNtt M - Facility lD (if applicable) S.Cert cation; •
v
i i
p l .. L -JrL'• •.��• 7 Z6--ZY -s
Physical Address,City,and Zii. p 1.� ,21 .'5 Si: ature Cetti5-,Orr
,,ntractor or Well•wner . Date
DAV/ 4 pm --a3-31-11065 By signing this form, I hereby cert(t that the u,ell(s) was (were)abandoned in
Coubry Parcel Identification No.(PIN) • accordance with ISA'NCAC 02C-:0100 or 2C.0200 Well Construction Standards
'''' •
and that a copy of this record has been provided to the well owner. •• 'Sb.iLatitude and longitude in degrees/minutes/seconds or decimal degrees: ---
(if rgc11geld,one latllongriss sufficient) 9.Site diagram or additional well details:
.35 t293 5(,l c N ,, l a*53 Q.Qj5 Co �y 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)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well cortstuctiorrrecord(s)ifavailable.For:ntitltiple injection or non-water supplywells -
ONLY.witlydte saute constructioa'abandomnnt,you can submit one form. =.
10a. For All Wells:-•Submit this form:.srithilr.a(l:;days:of•completion of well
6a. Ci•t l) :- abandonment to the following: %.-
_ •
1 /i//� • • . Division of Water Resources Information Processing Unit,
Gb.Total fuel(depth: 6A..2 (ft.) 161711Iail Service Center,Raleigh,NC 27699-1617
t� 10b,For Infection Wells:. In addition to sending the form to the address in 10a
• ' 6c.Borehole-di•a•meter: - t9q (in,) above,also submit one copy of this form within 30 days of completion of well
• • abandonment to the following:. •
•
•
•
6d.;Miatcr•level below ground surface: 24 l L �2• (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•
6n Outer casing length(if known): •
'r . (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion N
of well abandonment to the county, health department of the county where
6f,•Inner casing/tubing length(if known): "" (ft.) abandoned. Z
• 6g:Scr-een length(if known): — (ft.) -
•
•
1 J
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 r
• U