Wake_Well Abandonment_20241014 (2)

• WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL'-ABAf'4DONMENT DETAILS
N2 C I< 3, )V V\ $a N 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 I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
y5 7il G
NC Well Contractor Certification Number 7b..Approximate volume of water remaining in well(s): (gal.)
>h/ j - LT'Z E A it p S I i ,,, ,. FOR WATER SUPPLY WELLS ONLY:
Company(Name �T 44-ez
.. 7c.Type of disinfectant used: 1
2.Well Construction Permit#:
List all applicable well construction permits(If.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: I O OS.
3.Well use(check well use):
Water Supply Well: -- .`,7e.L Sealing- materials used(check all that apply):
❑Agricultural ❑�M�unicipal/Public - •ISNeat Cement-Grout ;"i. + 7 B"'"' entonite Chips or Pellets
O Geothermal(Heating/Cooling Supply) 67Residential Water Supply(single) 0 Sand Cemet{t arriiut;"-'-•' 'c•,.' 3 ../.m.00'Dry Clay
❑Industrial/Corrunercial OResidential Water Supply(shared) 0 Concrete Grout y ❑Drill Cuttings
❑irrigation 0 Specialty Grout 0 r I T 1 ! 2024
Gravel g
Non-Water Supply Well: - 0 BentoniteltSlu�rty . -..;7 ..??...Vk", 1..41.Other(explain under 7g)
❑Monitoring i : ❑Recovery . C•.,'c':,;c._,�;;.3
Injection Well: • - 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
GIRa4/61.. .2000 obs 4 Hot.E ?LAM 550
❑Aquifer Storage and Recovery ❑Salinity Barrier❑Aquifer Test ❑Stormwater Drainage /I etvr 3o0 I bs
❑Experimental Technology ❑Subsiderice Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 6114011E1+ 76," a20%
a a HdLE Pt ueri S`- 16'
4.Date well(s)abandoned: MOAT C E M E M T O-S
5a.Well location: ,
SgAr1EL GisapcCAI
Facility/OwnerName Faciy)Dft/Of applicable) S.Certification:
/y.25- cl6IJo6I.L r rL.L.s ?icwq /I - ;saxr q-as-44
Physical Address,City,and Zip Signature of Certifi a Contractor or Well Owner Date
W?Ke; By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No,(PIN) accordance with I SA NCAC 02C i 0100 or 2C.0200 Well Construction Standards
,..and that a-copy ofthis record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/hang is sufficient) p r 9.Site diagram or additional well details:
35.E'I r�a SOr N ` '7 i f I O39�3� W You may use the back of this page to provide additional well site details or well
d�v abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available.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
6a Well ID#: abandonment to.the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 2 a 0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: W in (in.) above,also submit one copy of ibis form within 30 days of completion of well
• abandonment to the following:
6d.Water level below ground surface: 26"" (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 7 II (ft.) 10c.For Water Supply&Infection 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): (ft.) abandoned.
6g.Screen length(if known): (ft) 1
• 1 I 1
Form GW-30 North Carolina Department of Environmental Quality--Division of Water Resources Revised 2-22-2016
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