Wake_Well Abandonment_20241022 (2)

WELL ABANDONMENT RECO" For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
inPb( '
�+ 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/d pth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
�^ r p wells abandoned: 1
of ! f1
IVI.Will 1.U11L1 atilUl l.\;I(IIIUat it IV UIIIUUI Tom' ��'�"'-:e....:.....,v.,.•.a•.�••:..:... ..-n..»:♦ o _, r ` `�
f �A
FOR WATER SUPPLY WELLS ONLY: `
Company fA
an Name 7c.Type of disinfectant used:
2.Well Construction Permit
List all applicable well construction permits(i.e.UI �.�C,County,State,Variance,etc.)ifknown i �� l� ' '
7d.Amount of disinfectant used: 99 �( _W�
3.Well use(check well use): C.U4
Water Supply Well: 7e.Sealine materials used(check all that apply): `r.
❑Agricultural 7R,
unicipal/Public ❑Neat Cement Grout wq/ p r
Bentonite Chips or Pellets:
❑Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection well: 7f.For each material selected above,provide amount of materials used:
pAquifer Recharge ❑Groundwater Remediation r 1
bAcidifer Storage and Recovery ❑Salinity Barrier �� � �`
❑Aquifer Test ❑Stormwater Drainage
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❑Experimental Technology ❑Subsidence Control 7g.provide a brief des ription of the abandonment procedure:
❑Geothermal(Closed Loop) []Traceri.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) arqvd
4.Date well(s)abandoned: ' '?4
Sa.Well location: . 1
61k !�'1�n-(S
Facility/Owner Name Facility lD#(if applicable) S.Certification:
-A 9.-;zo -
Physie4i Address,City,and Zip !,� q tl Si of certified Well Contractor!or Well Owner Date
� �V � - I Q By signing this form,I hereby cerafy that the wells)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C a 0100 or 2C.0200 Well Construction Standards
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long 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 may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)lfavailable.For multiple injection ornon-watersupply wells
ONLY with the same construction/abandonment,you can submit oneforni. 10a. For All Wells: Submit this form within 30 days of completion of well
6 N,Pu roil, abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: So (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:�__(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:
at) (ft.) Division of Water Resources,,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): h J A (ft.) toc.ror water auouty&imect IaLt vveus: in auumon to senamg the won to ute
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the cctmty health department of the county where
6L Inner casing/tubing length(if known): a' (ft.) abandoned.
6g.Screen length(if known): 0, (ft.)
Form CTW-10 North Carolina Department of Environmental OluLlity-Division of Water ResolLrces Revised 2-22-201 fi

WELL AHAND U1NlVE1V 1 Rli(.ORD �For internal Use ONLY;
1.Well Contractor Information: WELL ABANDONMENT DETAILS
p i
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: f
i; eil%uuuat:i� �,utiucutivn�NQUuct
C.W �Q m FOR WATER SUPPLY WELLS ONLY:
Company Name �) ( 650 7c.Type of disinfectant used: 1 �4
2.Well Construction Permit#:6 IlU i " ab A
List a!!applicable well construction enhits i.e.UIC,Cou» State,Variance,eta i lotown 1 Q 'c; ;:4r ,'"z•i 1•;
pp p ( ry' j f 7d.Amount of disinfectant used: 1 N 1 ' '� f"Z 9
3.Well use(check well use): Vil �024
Water Suavity Well: 7e.Sealing materials used(checkIall that an Yl:
❑Agricultural ❑ unicipal/Public ❑Neat Cement Grout 4 Bentonite
❑Geothermal (Heating/Cooling Supply) VRResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay '`y' ✓
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
[]Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer-Recharge ❑GroundwaterRemediation ' I�, ./4
[]Aquifer Storage and Recovery ❑Salinity Barrier l ��
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence-Control 7g,Provide a brief description of�the a ndonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) qrq uhi
i
4.Date well(s)abandoned: d
5a.Well location:
Facility/Owner me Facility iDtl(if applicable) 8.Certification:
go Frul drl a) 9-7�11
Physical.Address,City,and Zip Signage of Certified Well Contractor of Well Owner Date
By signing this form, I hereby certify that the wells)was(were) abandoned in
County Parcel Identification No.(PIN) accordance.ivith 15A NCAC 02C.0100 or 2C.020 0 Well Construction Standards
and that a copy oj'this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lWong 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 may also attach additional pages if necessary,
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructioMobandonment,you can submit one form. 10a. For All Wells: Submit this,
form within 30 days of completion of well
6n Weil iP#- abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: III,addition to sending the form to the address in 10a
6c.Borehole diameter: G (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cenier,Raleigh,NC 27699-1636
CL Inc.ror water bunmv ar urrecuo li wells: III aautuon to senang ute iornl to tile6e.Outer casing length(if known): (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): �(ft.) abandoned.
i
6g.Screen length(if known): C' (ft.)
Form CTW-30 North Carolina Department ofRnvironmental Ouality-Division of Water Resources Revised 2-22-2016