HomeMy WebLinkAboutWELL-05-2016-072613.TIF I
WELL ABANDONMENT RECORD
This form can be used For single or multiple wells
For Internal Use ONLY: I
1.Well Cootraclorr Information: WELL ABANDONMENT DETAILS
Well Contractor Name(or well owner 7a•Number of wells being abandoned: /
personally abandoning well on hisrber property) For multiple injection or non-wirier
d eonsrnrnion abandonment. soh urns ONLY with the same
z� �' r t you can submit one
NC Well Contractor Certification Number 7b.Approximate volume of water remaining In well(s): /8
4)
(gal)
L^ S'F FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: 70 a!o
2.Well Construction Permit 1!:
List all applicable we pertain(l.e.County,Steen Variance,Infection ea)(1b,own
7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(cheek all that a 1
°Agricultural PP M��° e
Oicipal/Public O Neat Cement Grout ❑ Brntonim Chips or Pellets
°Geothermal(Heeling/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑IndustriaVCommeseial °Residential Water Supply(shared) O Coocrzte Grout ❑ prig Clotting'
❑Specialty Grout 0 Gravel
Non-Water Supply Well: ❑Bcatonite Slurry rry ❑Other(explain under 7g)
°Recovery
Injection Well: 71.For each material selected above,provide amount of materials used:
❑Aquifer Recharge °Groundwater Remedianan /r j d
°Aquifer Storage and Recovery °Salinity Bartjer
°Aquifer Test °Stmmwatcr Drainage
OFxperimealal Technology °Sabsidrntt Control 7g.Provide a brief desWption of the abandonment procedure:
OGcothermal(Closed Loop) °Tracer /s� /
°Geothennal(Heating/Cooling Return) °Other(explain under 7g) rpent,Lie� /(�{t in D1 g, IOnn O iiI Ida(j.�'
� -P, /w,m COMcieke k
4.Dote well(s)abandoned: 6-14—/Z7 A°i,.1 DN`JO ei f C4-715 t)O` /e„ Ckr�AO
Sa.Well I lion: .lL�, ✓" �o lJ r
�fG n I 9'117b sur cP Lai a F
FaeiligYOsvaerName Facility MP applicable) 8.Certification:
14102 s c./6 A J y Add., t6sa g-ir.d,,, f C _ z-6/G
Pb� an d Zip Sigusvre of Certified Well Contractor or Well Owner Dare
C' By signing this form. I hereby ten&that the well(a) nos town)abandoned in
Patel Identification No.(PIN) accordance nigh/54 NCAC 02C.0100 or 2C.0200 Well Constntaion Standards
and that a copy of this record has been provided to the nett owner.
;b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
Of well field.one lakmg is sufficient) // `p 9.Site diagram or additional well details:
7y�LTV 77 45? N —SYe /Lit 7/6 ,V You may use the back of this page to provide additional yell sire details or well
abandonment details. You may also attach additional pages if necessary.
CONSRRUCYIO\DETAILS OF\VEi ka ACING aBAM) NED $URMTITA'.INSTRI1rTIONS
Mark writ conerr lion rerord(el If available. For mu!nple infMeon or nvmnmer supply
.rt,ONLY with the same awnranbm'abatonmens you can submit one farm. 10a.For All Wells: Submit this form within 30 days of completion of well
tier.Well mH: abandonment to the following:
Division of Water Resources,Information Processing Milt,
Ob.Tool well depth: 2,y/
(D,) 1617 AMU Service Center,Raleigh,NC 27699-1617
• lob.for lnlertlon Wells: in addition on sending the form to the address in 10a
ZQ above,also submit one copy of this form within 30 days of completion of well
6e Borehole diameter. Oa.)
abandonment to the following:
-
• Division of Water Resources,Underground Injection Control Program,
6d-Water level below ground surface: 7 3' (R)
1636 Mail Service Center,Raleigh,NC 17699-1636
IOe.For water Supply ft Dilation Wells: In addition to sending the form to
6e.Outer casing length(if known): CM the addresses above, also submit one
( J 4 copy of this form within 30 days of
completion of well abandonment to the county health department of the count)
6L lancr rasiogJmbing'Iength(if known): (D) where abandoned.
•
•
es.Screen length Of knee"): .(IL) '
w"