Wake_Well Abandonment_20241115 (5)

WELL ABANDONMENT RECORD For Internal use ONLY: !
This form can be used for single or multiple wells
i
1.Well ontractor I P Irmatt''pn: WELL ABANDONMENT DETAILS r
� L""g__ 7a.Number of wells tieing 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
33
construction'abandonnienr,you can subnrir one form.
3 I.
NC We11 Con torCe ific lion Number 7b.Approximate volume of water remaining in well(s):
d >lat S�OL, FAmount
UPPLY WELLS ONLY:
Company Name fectant used:
A
2.Well Construction Permit#:
List all applicable wellpermits r e.CougK Stare,Variance,Injection,etc.)if known sinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing material used(c�ieS kill lhat`apply):I
DAgricultural ❑Municipal/Public ❑Neat Cement Grout 0 &;in onite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout N 0 V 1 i' 2 Q 26 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout lr' ""r ?' r ``r'"�O%Gravel
-Nop
-Water Supply Will: ❑Bentonite Slurry ❑ Other(explain under 7g)
onitoring ❑Recovery
ection Well: 7f.For each materials lect d above provide amount of
I terials used:
❑Aquifer Recharge ❑Groundwater Remediation WAS.
11. fit. C�` � �—�y �q//�i�i� � j��
❑Aquifer Storage and Recovery ❑Salinity Barrier /
❑Aquifer Test ❑Stormwater Drainage lDjS, �i dr �yd
❑Experimental Technology ❑Subsidence Control ?g.Pro ide a brief description of fhe'abandonment procedure: ,,e
❑Geotherma((Closed Loop) ❑Tracer 2 m�s� 4 /u ) �odtd Z 4 k1e
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) /C L! ! I
r r., vat` w ed . 1p
4.Date well(s)abandoned:
Sa.Well location: spy_ I't�G� Sv �'tiCd
our wett: Ali P4
Facility/Owner Name n Facility ID#(if applicable) S.�of ication:
3b z.F �k� 41 , C 44 n'6 7,16©Lc ,� - 1��� � -
Physical Address,City,and Zip S46ture oftertifiedWell Contractor or Well Owner Dal
y ok-e By signing this form, 1 hereby certih,ithal the wells)was(vere)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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
a "' q_q '1 �j �r �D Z�a You may use the back of this page to provide additional well site details or well
J✓ T N c/ J W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach well construction record(s)if available. For nnrhiple injection or non-water supply
wells ONLY with the same cons
s-tru�ctio1nlapando�nrinent,you can.subinit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: t ' `�" ✓�V abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (it.)
1617 Mail Service Center,Raleigh,NC 27699-1617
Lf 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
tic.Borehole diameter: (in.) abandonment to the following:
1 l t 1 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: v (ft.) 1636 Mail Service Center,Raleigh,NC 27699.1636
Z, 10c. For Water Supply&Iniectio I 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 the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft.) I�
4
6g.Screen length(if known): /Q 1 (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

\ I 1
f
WELL ABANDONMENT RECORD ' For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well ontractor nform ion: WELL ABANDONMENT DETAILS I
r
1/i� t 91 5alee 7a.Number ofwells being abandII nled:
Well Contractor Name(or well owner personally,abandoning well on Molar property) For multiple injection or non-water supply wells ONLY with the same
constntctionlabandonment,you can sub'mil one form.
NC Well Contractor Cc sc hon Number 7b.Approximate volume of water remaining in well(s): (gah),
FOR WATER SUPPLY WELLS ONLY:
Company Name '7c.Type ofdisinfectant used:—' '"
2.Well Construction Permit M
List all applicable wellpern,its(i.e.County,State,Variance,Injection,etc)ifknown 7d.Amount of disinfectant used: gN
3.Well use(check well use):
Water Supply Well: 7e Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic Neat Cement Grout.-, y _a �t nBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) Cl Sand Cement Grout, , Cv.> '!' gip^l7'Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) O Concrete Grout NOV 1 s L024 ❑ Drill Cuttings
OIrri ation ❑ Specialty Grout 1 ❑ Gravel
n-Water Supply Well: ❑Bentonite Slurry �: r' r ,.'.p OfFter(explain under 7
onitoring ❑Recovery a.-
g)
lecfion Well: UFor each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation f)/J 5,�(Jf-'�-t pot �jjj = A.f ��p�Q /-�l�/1`
❑Aquifer Storage and Recovery ❑Salinity Barrier /�"ly
❑Aquifer Test ❑Stormwater Drainage I��' r"'�` r� "$!'� `7G1�, ls✓! y
OExperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer p�e
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
J (/ 17 ,arm �'c�r
4.Date well(s)abandoned: It( - / wv � s
L A- 10�E%1 /
5a.Well location: W C� �/yE 5't/ �- rN Pe�/I e¢L �@y1tPnP w+�6••
W, � vrc
Facility/Owner Nam Facility IDII(ifopplicable) S.Cer i,e ion:
3Gle" 161,1) y� ��
Physical Address,City,and Zip egna re of Certified Well Contractor or;Well Owner Date
e. By signing this form,,!hereby ceriifj,;that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 1C.0200 Well Construction Standards
and that a copy ojthis record has been provided to the ivell owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one Ist/long is sufficient) 9.Site diagram or additional,well details:
4Q� 3 S,05 1 W You may use the back of this page to provide additional well site details or well
t t 1 t! U abandonment details. You may also!attach'additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)#available. For mtdtiple injection or non-water supply p
wells ONLY with the same constructionlabandonment,yore can submit one form. 10a. For All Wells: Submit this!form within 30 days of completion of well
6a.Well ID$: VV 1( abandonment to the following:
Division of Water Resources,Information Processing Unit,
p t 66.Total well depth: (it.)
1617 Mail Service Center,Raleigh,NC 27699-1617
0
I
f� jl 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: V (in,) above,also submit one copy of this form within 30 days of completion of well
Q ` abandonment to the following:
3 U t (it,) Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface
1636 Mail Service Center,Raleigh,NC 27699.1636
) 10c.For Water Supply&Infection 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
1� completion of well abandonment to the county health department of the county
Where abandoned. I
U Inner casing/tubing length(if known): (ft.)
l
6g.Screen length(if known): /0 (ft.) ,
1
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013