The URL can be used to link to this page

Home My WebLink AboutBeaufort_Well Abandonment_20241101 - WELL AI5ANJJ(DNIVILN I RECORD For Internal Use ONLY: ' ' 1.Well Contractor IInformation: WELL ABANDONMENT DETAILS---, -.bS t t/l Ife57 -S5 7a.For Geoprobe/DPT or Closed-Loop Gtenleirosal'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 tad Indicate TOTAL NUMBER of , . i t vi A .. -• ` wells abandoned' 1 NC Well Coniractor.Certification Number - t'b-Approximate volume of water'rraesining in well(s): (gal.) I il e.V U" 1. • 1 `u Swt Or i I I v15 FOR WATER SL-PPLY-WELLS'ONLY:• - ' Company Name,s,:. -7c:-Tvpe-of disinfectant-used: -,•-' r r11 T H ' '- 2.Wel1.C:onstruction.Permit# - - i List all applicable well construction permits(i.a.UIC,County.State.Variance,etc.)ifknonn .."i.' ' '' • ''" •, 7d:Amount of disinfectant used:' • / . 3.Well use(check Well use): _ - . ' • - " . Water Supply Well: 77�e..S�Sealing materials used(check!all that apply: CAgricultural ❑Municipal/Public !'Neat Cement Grout it Q'Bentonite Chips or Pellets EGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout i 0 Dry Clay ,eilndustrial/Cotmnercial ❑Residential Water Supply(shared) 0 Concrete Grout i0 Drill Cuttings Irrigation 0 Specialty Grout 0 Gravel Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) GMonitoring-. -- - ---ORecovery - Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation �� !Q14,5 }o-� r ��w'ram, 1,� I ; ❑Aquifer Storage and Recovery ❑Salinity Barrier �'N vL 1 i)�l C�f� a <�4,...,"...•)4.' n •an �A��'_=` ❑Aquifer Test ❑StormwaterDrainage ee.viko.R1 't `o e_ U"!i () k.c +Jf tf .-j ! LUZ`► C Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: OGeothermal(Closed Loop) ❑Tracer I Infc4Fp,a.i-an r"i:^a:e.a Y" is/t't. GGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) fD 1, 1 `D'ilfsl Kt0G f _ Y o LI�`t [c l C?w1t l i^•/,1�tJ "�o vJae 141 4;fiate well(s)abandoned:.:/() s g'1 �J I /- U, �.- . .•-�-fewtce-. (. .,- `rGle `rt'`s e)- -Sa.Well location: IL j. ' t� , po.utrc r In6 e /9I05 Sc' cue Fpeility'Owner Name Facility ID#(if applicable) 8.Certification:, ., , ;1, .. • • - . • 15 3 b a_ `3(%) 5 g2c3o to ( i ,' r0--a6-�y Physical Address,City,and Zip _ Sienatur of Certified Well Co dractor or Well Owner Date SAA By signing this form, I hereby eery f'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. tb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 I - , (if well field,one lat/long is sufficient) 9.Site diagram or additional well,details: ' 3113 6 N ' L. Gr5r1 3c `�, You may use the back of this page to provide additional well site details or well J l J p 0 0�+ abandonment details. You may also attach additional pages if necessary. - -CONSTRUCTION-DETAILS OF WELL(S)BEING ABANDONED- - - •SUII\4IT"TAI,INSTRUCTIONS Utuc/r well construction records)ifavailable. For multiple injection or non-water supply wells ONLY with the some construction abandonment,you can submit oneJorm. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: (--,w 064 abandonment to the following: , Division of Water Resources,Information Processing Unit, 6h.'Total well depth: 16 c (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 I ft lob.For Injection Wells:. In addition to sending the form to the address in 10a 6c.Borehole diameter: '7 la (in.) above. also submit one copy of this form within 30 days of completion of well abandonment to the following: 1 6d.Water level below ground surface: 7e31 (ft.) Division of Water Resources,;Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 1, i t 6e.Outer casing length(if known): A (ft.) 10c.For Water Supply&Injection 6Vction 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. 7 Inner casing/tubing length(if known): � ? (ft.) abandoned. j. 6g.Screen length(if known): 3V (ft.) [ j I Form GW-30 North Carolina Department of Environmental quality-Division of Water Resources Revised 2-22-2016 . IN) aila I1115AINIJunIVIV_AN 1 1CLt,LUKIJ For Internal Use ONLY: I t 1.Well Contractorr Information:orx WELL ABANDONMENT DETAILS CY S 7a.For Geoprobe/DPT or Closed=Loop Geothermal Wells having the same Well Contractor Name(or well ow er personally abandoning well on his.rher property) well construction/depth,only 1 GW f30 is needed. Indicate TOTAL NUMBER of cl 1 1 A wells abandoned: I I NC Well Contractor Certification Number 6 7b.Approximate volume of waterlremaining in well(s): (gal.) ` - (A0t 1 f(Itc'•J FOR WATER SUPPLY WELLS:ONLY: Company {� Name . k 7c.Type of disinfectant used: 2.Well Construction Permit#: 1 I List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.)if known �r 7d.Amount of disinfectant used:I' r 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural • ❑Municipal/Public Teat Cement Grout B'Bentonite Chips or Pellets ^�Geothermal(Heating/Cooling Supply) :Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay P1lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings °'" ,-. ,, ❑lrrittation 0 Specialty Grout 0 Gravel y..". _- • > Non-Water Supply Well: G s ° , "" O--,e 't. 11„a, 0 Bentonite Slurry 0 Other(explain under 7g)�" ❑Mon itoring --- - ORecovery -- -- - - - - -NOV e-, l 9 Injection Well: 7f.For each material selected above,provide amount of material?;used�024 ❑A uifer Recharge %,` ` A� �) CC -•• ,, q ❑GroundwaterRemediation �t1a a�tt C'wtF b cY 1r;v,r�,� ,, f3'r;"`uF_^y ❑Aquifer Storage and Recovery ❑Salinity Barrier 8 v _ ;s::11 :a ❑Aquifer Test ❑Stormwater Drainage k0k lilt 7 )VcJG .❑Experimental Technology ❑Subsidence Control ❑Geotherntal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) %ante r ruct,t (r) 1' , i l.C.II 60-1-o wl ( ' 1_,,,,, .P,, 4ewtle `(C e T.Date well(s)abandoned: rQ`-(93— ,_2� I l // s1 5a.Well location: J t Facility/Owner Name Facility ID#(if applicable) 8.Certification: i ISO WC- Hu/ 306 S a .75��(, C , I, /o--aG-,P'1 Physical Address City,and Zip Signature o rtified Well Contra/.r or Well Owner Date tt� ft`1 O`r By signing this forum, 1 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 bleeit provided to the well owner. Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: oft:ell field,on`ealatllong is sufficient) 9.Site diagram or additional well details: IS r 10 '(0 N ')_. Isrja 39 `,(, 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- - - SL1B11ITTAL INSTRUCTIONS Attach well consnuc-lion record(s)if available.For multiple injection or non-water supply wells ONLY with the same construction abandonment,ion can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 68.Well ID#: G.W LXDIR abandonment to the following: . . ec Division of Water Resources,Information Processing Unit, r1 6b.Total well depth: C l5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 I f 10b.For Infection Wells: In-addition to sending the form to the address in 10a 6c.Borehole diameter: /a (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: -7 P. (ft.) Division of Water Resources„Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): pV (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 of well abandonment to the county health department of the county where 6f.Inner casing/tubing length(if known): (ft.) abandoned. I I i 6g.Screen length(if known): 0 (ft.) I I Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016