Wake_Well Abandonment_20241115 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY: `
This form can be used for single or multiple wells ,
1.Well ontracttor Intfor�ation: WELL ABANDONMENT DETAILS
7a.Number of wells being abandol ed:
Well Contractor Name(or well owner personally abandoning well on histherproperty) For multiple injection or non-water supply wells ONLY with the same
—3 3 3 n construction/abandonment,you can submit tine form.
NC Well Contractor Certification Number 7b.Approximate volume of water I emaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well permirs fl.e.County,State,Variance,Injection,etc.)ifknown 7d.Amount of disinfectant used: V i
3.Well use(check well use):
Water Supply Well: 7e Sealing materials used(checkall that DI
❑Agricultural ❑Municipal/Public eat Cement Grout 1 7— I;!, ±,(il --— to Chips or Pellets
Y.❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Sand Cement Grout : "� Rr t,,l.!Z" d ;C]pry,Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout NOV �n❑'pDrill Cuttings
❑Irri tion ❑ Specialty Grout 2a?firavel
Non-Water Supply Well: ❑Bentonite Slurry 11.; ❑Other(explain under 7g)
onitoring. ❑Recovery �,;;.- •.;;...-.,
✓f3 "
njection Well: 71,For each material selected above;pidvide amount of Materials used:
❑Aquifer Recharge ❑Groundwater Remediation 75. 6&4nt4 rein kd'Qj
❑Aquifer Storage and Recovery ❑Salinity Barrier /—� ,
❑Aquifer Test ❑Stormwater Drainage /01 L5
❑Experimental Technology ❑Subsidence Control 7P.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer S `/�t� weA O ! :,/ fo�� ��W
❑Geothermal(I-Ieating/Cooling Return) ❑Other(explain under 7g) Ts fh G� r/K
l- _0 Cd I 1'1^ sti2 s s
4.Date well(s)abandoned: �_41a� 1Q'271Ji7//t r p J_��T .
Sa.Well location: y l� (iw ve �sttt� ivw nn / a4"�
�-E7y 1p
Facility/Owner Name Facility lD#(ifapplicable) Cerfi i r ! e 1 /_ K �• t' 6
coy S
Physical Add ks�
ty,and Zip ature of Certified Well Contractor or Well Owner Date
/iJ G By signing this form, 1,hereby cer1#5,that the wells)was(vere)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
J 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 latnong is sufficient) 9.Site diagram or additional well details:
�pr L� p 9,/ �r1 A ' You may use the back of this page to provide additional well site details,or well
` ✓�� d Fi N y ' JV►Q l// W abandonment details. You may also attach additional pages if necessary. '
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLY with the some construction/abandonment,you can submit one form. 1 Oa. For All Wells Submit this form within 30 days of completion of well
NJ . abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
(�6b.Total well depth: 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
Li 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:
I,
j L Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: V (ft•) 1636 Mail Service Center,Raleigh,NC 27699.1636
/n t' 10c,For Water Sunuly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): "7 (ft.) the address(es) above, also submit)one copy of this form within 30 days of
completion of well abandonment to'Ithe county health department of the county
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): _(ft.) i
Fort GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Res,urces Revised August 2013

,
i•
WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well C ntraeto_r/I�nformation: WELL ABANDONMENT DETAILS
��r� 7a.Number ofwells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
C constnrction/abandonment,you can submit one fonm
-33
NC Well Contractor Certification Number
7b.Approximate volume of wafer�remaining in well(s):
FOR WATER SUPPLY WELLS;ONLY:
Company Name 7c.TyTe ofdisinfectant used: i
2.Well Construction Permit M
List all applicable well perm»is(i.e.County;State,Variance,Injection,etc.)ijknomw
7d.Amount of disinfectant used:
3.Well use(check well use):
7e Scaling materials used check all that apply):
Water Supply Well: g ( p�P Y): ,
❑Agricultural ❑MunicipaUPublic Neat Cement Grout T^ entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Sand Cement Grout; ? > ; +''.;/❑Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑Concrete Grout C] Drill Cuttings
❑Irri ation ❑ Specialty Grout NOV 1 c• 2024❑ Gravel
n-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
Monitoring ❑Recovery
„l—
njection Well: 7f.For each ma erial sal ed aboye;:provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation e/s,
[]Aquifer Storage and Recovery ❑Salinity Barrier /D J��
❑Aquifer Test ❑Stormwater Drainage [
I
❑Experimental Technology ❑Subsidence Control 7 .Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer UtI C_ O�,�y�f pal : .. 5 �bIL/� &-ei //
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) "`t' 1�[ t
t Z liti W'J r"stht d �' rom i��S,14-�
4.Date well(s)abandoned: i 7 ,rpb 1t� ( �
Sa.Well location: his Otd{^ t• cs' l� OW �1.Q<� /�`(�GJjZrh
Facility/Owner Na a Facility ID#(itapplicable) g•C. to fi n:
Physical,Add r ss,City,and Zip Si ature of ertified Well Contractor or Well Owner Date `
By signing this form,I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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 latAong is sufficient) 9.Site diagram or additional well details:
r Q® 1 D �O �1 O You may use the back of this page to provide additional well site details or well
0N I � t ZI W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLYwith the same construction/abandontnent,.yotr can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDfI: VV- abandonment to the following:
i
f Division of Water Resources,Information Processing Unit,
66.Total well depth:
1617 Mail Service Center,Raleigh,NC 27699-1617
� (ft.)'
10b.For Iniection Wells: In addition to sending the form to the address in 102
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: [ ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699.1636
10c.For Water Supply&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 to thecounty health department of the county
6E Inner casing/tubing length(if known): (ft.)
where abandoned.
D1
6g.Screen length(if known): (ft.)
i
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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