Orange_Well Abandonment_20241115

WELL ABANDONMENT RECORD For Internal Use ONLY:
I
1.Well
Contractor Information: WELL ABANDONMENT DETAILS
Air C.k 4)ekiNA 6)U • 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
i1 0 C. wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): (Oa) (gal.)
Pt 4e R W1 Z 14 iz. ,i NI L 'FOR WATER SUPPLY WELLS''ONLY:
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Company Name 1 T
O 7c.Type of disinfectant used: I TI 7
2.Well Construction Permit#:
w J r !'
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)if known3 7d.Amount of disinfectant used:I_ Q"f.
3.Well use(check well use):
Water Supply Well: 7e Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ii Neat Cement Grout NBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial °Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout i °Gravel
Non-Water Supply Well: ❑Bentonite Slurry i 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation '`O I{�� ii lJ,n pr r�!_
❑Aquifer Storage and Recovery 0 Salinity Bather ��++ WC '�,Jft,pr,��a.+['�s V w
❑Aquifer Test ❑StormwaterDrainage I50 ibS /VLI9! c.EMS l "l
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �,f 1 „ l f w „� n I ',
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) / —51 PlSuxeo Hece /�LJ►C7
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/0.-28'-ay ' l Pt�weE0 NEST etM�"NT
4.Date well(s)abandoned: . . '^ -_ --i
5a.Well location:
'! -P-FA0v Acke2-1- ' NOV 1 5 2624
FacilitylOwnerName Facility 3D1/(If applicable) 8.Certification:
5i`}' Olt l�',IIS boao�5ti ►� lu�bfl NC �1�n� vl72i k /C '` , .-- , ; z2q
Physical Address,City,and Zip Signature ofCertifill Contractor or Well Owner Date
ORAtCe- 0S03%072 ' ,
By signing this form, 1 hereby certi 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.
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) y/ 9.Site diagram or additional well details: •
3/„' O 0 312 Sq N -7 9 t 9 9 1 17 Q w You may use the back of this page to provide additional well site details or well
`r abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS.
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. I.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: , 1 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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. i
a0 Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: nn (ft-) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): o. \ (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
t.
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g..Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016