HomeMy WebLinkAboutWELL-10-2015-065336.TIF •
mer. 14 .2016 07 : 17 AM Mid South Well & Pump Com 7045395515 PAGE. 1/ 1
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r■ WELL ABANDONMENT RECORD parinlanial Uee ONLY:
%■ This limn can housed for single ur multiple wells
1.Well Contractor information: WEL4ANDONMENT DETAILS
30,--S5 R. 0060I
7n,Number of wells being abandoned:
Well(.'nnlrodnr Nome(or well owner personally abandoning we II on hlaher property) For raalripla Injection or non-water supply welly ONLY with the scone
1('ACK-1 M1 G eorutrocvlan/abandonmont,yen con submit one/aria. ...[�
NC Well Contractor Certification Number
7b.Approximate volume of wider remaining In well(s): l�l (gal.)
Y ` r61 .90m-p.\- kA�) l` FOR WATER SUPPLY WELLS ONLY: 1_
Company Name //yy-_��� // 7c.Type of disinfectant used:1� b f 1 le(
2.Well Construction Permit/; OCAS\3W pp
I.la all apldlcaNe well permne lln.Cnanlp Sae Variance,becalm;etc.)II known 7d.Amount of disinfectant used: I\D O i'l
3.Well use(cheek well use):
Water Supply Welk 7o.Sealing material'used(check all that apply)i
CAgrieolturnl OMunicipaWWbllc 'iltsNeot Cement Grout 0 Bentonite Chips or Pullets
°Geothermal(Heating/Cooling Supply) °Residential WUtct Supply(single) O Sand Cement Grout 0 Dry Clay
°IndustrlaVCemmerciul °Residential Water Supply(shared) 0 Concrete Grout ° Drill Cutlings
°irrigation 0 Specialty Grout O Grovel
Non-Water Supply Well: 0 Bentonite Slurry °Older(explain under 7g)
°Moniluring °Recovery
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Injection Well: 7f.For each material selected above,provide amount of materials naiads
°Aquifer Recharge COruundwiuer Remedlntlon e1'c I_i crd_S
°Aquifer Storage end Recovery °Salinity Barrier
OAqulfer Ten OStormwotcr Drainage
°Experimental Technology °Subsidence Control 7g.Provide a brief description of the abandonment procedure:
CGeothonnal(Closed Loop) °Tracer �llM� Cocci C.-4 L.- Y
COM�°Geothermal(Renting/Cooling Realm) °Other(explain under 7g)
'7 f _ QoccicA c- k ruct -1-Ihru ` ,
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4.Dotewell(s)abandoned:1\-aJ- IW ` u„,,- Orr u Ct„. '1-C, b.. 1- WrL ,
Sal Well location: \rte. b`L f tM^\t-1^ fiC `
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Facllhy/Owner Name Facility IDs Of apuceble) CuAtOcatlon:
■Lytio asT S-- Q.E. *Ic_? 3-G\ ,11/41_,C.,_ c.3,,,c C2 11-D3-1(0
PhysicalAAddress.City,and 21p Slgnu ini ofCmtiful Well Cunlmutorr or Well Owner Dale
J
\aLa. 1t--_- By signing Ibis,form. I herrbh loftily that the well(s)was Nero/•shown/ones/In
County Parcel identlilcadon No.(PIN) accordance with 154 NC'4C'020.0/00 or 2C.0100 NMI:C''cnxtturtlon Slumlords
and that a copy Vilify recant has been pmvided to the well owner.
Sb.Latitude and longitude In dagreos/minutes/seconds or decimal degrees:
(If well field,one hi/long In madam) 9.Site diagnun or uddillonul well details:
You may use the back of this pap to provide additional well site details or well
N W abandomment details, You may also utt itch additional page:if neceeauty.
.,. •, a s t v : �. a i. SUDMIVTAL INSTRUCTIONS
Attach well conaranfon record(*)0'notable. For multiple Injection or ton-trot'merely
walla ONLYw'in,rho sumo ccrmm¢tIon/abandamaum.pmt can submit raw/orrn, 10a. jtor All Woljpt Submit this form within 30 days of completion of well
6a.Well IN: abandonment to the following:
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Division of Water Resources.Information Processing Unit,
6b.Total well depth: `4 (R.) 1617 Service Center,Raleigh,NC 27699.1617
`� IOb.Fqf Injection Wefi : In addition to sending the form to the addrexa in Ina
6e.Borehole diameter; JO (In.) phnve,also submit one copy of tile form within 30 days of completion of well
abandonment to the following: •
6d.Water level below ground surface: (D.) DIvIAoa of Water Resources,Underground Injection Control Program,
`\ (� 1636 Mall Service Center,Raleigh,NC 27699-1636
6e.Outer sexing length(If known): an (ft.) 10c.)'or Water Sllgply 6tJnlectioa WtDa: In addition to sending the rem:to
the addressees) above, also subunit one copy of lids form within 30 days of
completion of well nhandonment to the county health department of the county
Of.Inner caning/tubing length(If known): r On
where abandoned.
6g.Screen length(if known): NIA (D.) .
• Form OW-313 North Carolina Deportment o('l'.nvlronment and Naluml Re sources—Division of Water Resorce. Revised August 2013