Northampton_Well Abandonment_20241001

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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
wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name
C' 7c.Type of disinfectant used:
2.Well Construction Permit#:_
list all applicable xtel/construction permicr(i.e'.VIC, ounn>,Sratr. Variance,etc.)i(6eorm t rt
7d.Amount of disinfectant used:
3.Well use(cheek well use):
Water Supply Well: 7e.Sealing materials used(check all that app
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) �JResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay❑IndustriaVCommercial csidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Oltrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry q Other,(explain under 7g)
❑Monitoring ❑Recovery 1,'% ,'-'
injection Well: 7f.For each aterisl leered above,provide amoanfof�raterilAs Lwd:%
❑Aquifer Recharge OGroundwater Remediation I> �J� 0 C T d i 20?4
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer t�t t L'M L,4'7� r/Vt•/t/(7
❑Geothermal(Heatin Cooling Return) ❑Other(explain under 7g) `rS
4.Date well(s)abandoned:
5a.Well location:
FacilitytOwnerName Facility iD#(if applicable) 8.Certification: (�
Physical Address,City,and Zip signature o fied elector or Well f •�f Date I
at�itAr)PTA C t t
� � r By signing this(ornr, herebv certi �that the ivell(s) was(mere)abandoned in
County Parcel Iden fiction No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constriction Standards
and that a coP),of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
V 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 SUBMITTAL INSTRUCTIONS
AttachN•ellewtstructionrecord(r)ifavailable.For multiple i*ctionornon-watersupplylVells
ONLY utitb the saner c•onstructionlabandonnient,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: /�/1 )1\ abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: ('1 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
j l 10b.For Iniection Wells: In addition to sending the foram to the address in 10a
6c.Borehole diameter: L�L (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:
2— (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
(/ r (C 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
fie.Outer casing length(if known): /1 (ft.) 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): ,^1 �^t^ (ft.) abandoned.
6g.Screen length(if known): —/t 00
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Remised 2-22-2016