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Home My WebLink AboutWake_Well Abandonment_20241115 WELL ABANDONMENT RECORD For Internal Use 014LY: This form can be used for single or multiple wells 1.Z ContractorInformation: WELL ABANDONMENT DETAILS -, 'sje.- 79.Number of wells being aband Ined: Well Contractor Name(or well owner personally abandoning well on his/berproperty) For multiple injection or non-water mtpply wells ONLY with the sane �� rnnstnrction/abandonment,you can submit one farm. 7b.Approximate volume of water,'remaining in well(s): NC WKCtraforce 5cattonNumber FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: /V _ +2.Well Construction Permit#: JV List all applicable wel!permfts(i.e.County,State,Variance,Injection,etc.)if known - 7d.Amount of disinfectant used:.). 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that ap ly): OAgricultural ❑Municipal/Public Neat Cement Grout -IBentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Sand Cement Grout, :' '* " " R}Dry Clay ❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grouts:�` '° ❑ Drill Cuttings oirriga`lion ❑ Specialty Grout [Q24 ❑ Gravel -Water Supply Well: ❑Bentonite Slurry 0 Other(explain under 7g) nitoring ❑Recovery 7L For each mat6liil'sele red ab""iFE rovide amount of materials used: njection Well: .,,,, ElAquifer Recharge ❑Groundwater Remediation �J�R� / � ( �%as OAQuifer Storage and Recovery ❑Salinity Barrier l D As. I y�� oAft, /� ❑A uifer Test ❑Stormwater Drainage r]/ /'D �i f'p N 7 ht ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Vit t* DbL � ittALdr -) ui- K� ❑Geothermal(Heating(Cooling Return) ❑Other(explain under 7g) L l V i+r to p ��( ' L�l I'+" 1K C�+t7 S'uT�GG� 4.Date well(s)abandoned: r �� kujnN 4Lh11h, - J Agtf 4 " 52.Well location: r docy 1'e# i fled— IN Facility/Owner Nam Facility[DM(if applicable) 8• ! ' e�fi tion: t(w)lr Physical Address,City,and Zip SifiWreofCertified Well Contractor or Well Owner Date Ofel ke- By signing this form, I hereby cer16,that the weU(sJ was(were)abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the weU owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: 35"' N b"4?r 3� CJ O3/_ W You may use the back of this page to provide additional well site details or well G G abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Artach well construction record(s)ff available. For nttrltiple injection or non-wafer supply wells ONLY with the saune constr+u ctionlaba donnenr,your can sutbtnft one fonu' 10a. For All Wells: Submit this form within 30 days of completion of well 69.Well ID#: ��"_� � abandonment to the following: / (ft.) Division of Water Resources,Information Processing Unit, 6b.Total well depth: ) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For lniection Wells: In addition to sending the form to the address in 10a above,also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter: (in.) abandonment to the following: �f �Jj� Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: [ �i (ft.) 1636 Mail Service Cente',Raleigh,NC 27699-1636 6e.Outer casing length(if known): ryV (ft.) loc.For Water Supniv&Iniection�Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of t completion of well abandonment to the county health department of the county where abandoned. ; 6E liner casing/tubing length(if known): (ft.) 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013 i WELL ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1 1.Wel ontractor InMilew.- n• WELL ABANDONMENT DETAILS A7a.Number of wells being abandol ed: i J Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple tnjecrion or non-water supply wells OIVIY with the same constructiadabandonment,you can submI.it one form. 7b.Approximate volume ofwater remaining in well($): NC Well Contractor Cc ification Number FOR WATER SUPPLY WELLS ONLY: A� Company Name 7c.Type ofdisinfectantused: r" 2.Well Construction Permit M A, List all applicable well permits(i.e.County,State,Variance,Injection,ere.)ijknown 17d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e Sealing materials used(check all that apply): ❑Agricultural ❑MunicipaVPublic Neat Cement GroutBentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Sand Cement Grout A`Dry Clay ❑Industrial/Commercial DResidential Water Su ❑Concrete Grout i ` ' Supply(shared) a,� �i;❑��D911 Cuttings irrigation ❑ Specialty Grout d Gravel I Non-Water Supply Well: ❑Bentonite Slurry lu+ 2024❑Other(explain under 7g) Monitoring ❑Recovery njection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation °�ef9S•` '" 2fr"G�3. (ivG ❑Aquifer Storage and Recovery ❑Salinity Barrier �D��I.Jt�� , ®�� ❑Aquifer Test ❑Stomiwater Drainage �e� Yto t?/'bjfil"e ❑Experimental Technology ❑Subsidence Control 7g.Pr vide a brief description of the abandonment procedure: OGeothermal(Closed Loop) ❑Tracer �// OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) V P yD 1 t 4w, jr.e4l j Dr,, 2/c�� r�,rl S�tr 4.Date well(s)abandoned: g'ygG �1I j�A/ - �J?i4,7ryere-+ /7#e.. 52.Well location: 9-it t: e? {� -1 Facility/Owner Name lity ID#(ifapplicable) 8•Certr ation: L Ad x1e4ii n, 4 stir riu z physical Addre s,City,and Zip lure of Certified We 1 Contractor ell Owner Date By signing this form,j hereby cerlify that the well(s)was(vere)abandoned in County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lot/long is sufficient) 9.Site diagram or additional well details: �f �+ h a You may use the back of this page to provide additional well site details or well N " �� W abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well comlivelion record(s)tf available. For mMtitple/nject/on or Man-wafer supply, wells ONLY with the same constructionlabandonrnenr,you con.subrnit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well IDM UV —�0 abandonment to the following: Division of Water Resources,Information Processing Unit, �j6.1 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Total well depth: (ft.) • ti 41 10b.For Iniection Wells: In addition to sending the form to the address in 10a above,also submit one copy of this,,form within 30 days of completion of well 6c.Borehole diameter: (in.) abandonment to the following: Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: " ► 6 1 (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636 LLI v r 10c.For Water Suooly&Iniection Wells: In addition to sending the form to 6e Outer casing length(if known): (ft.) the address(es) above, also submit!one copy of this form within 30 days of completion of well abandonment totthe county health department of the county 6E Inner casing/tubing length(if known): where abandoned.�' (ft.) I n t J+ 6g.Screen length(if known): Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013