HomeMy WebLinkAboutWELL-05-2016-072614.TIF WELL ABANDONMENT RECORD Pox internal Ow ONLY
This form can be used Er single or multiple avant O
1.Well Contractor Intbrmadon: WELLADANDONAIENTDETA/LS 1
'011 ex g e et C 7a.Number of wells being abandoned: I
Well Cainetw Namo(or ma owner penmaly abandoning tell on his'her property) Per mnlnpl. Iilanlon or non•earer ripply Wells OIyLY well ZS came
3 t1 —/- ,( coturnlrllon abandonment,you ran salmi;one Jam. tt 5
NC Well Waasnoe Ccnl0eaden Numbs 7b.Approllmate volume of water remaining In rid*); /J 7 e
rr �
��Iwt?. CLe1 �,e tks-s0 �SC'FIJlte C FOR WATER SUPPLY WELLS ONLY:
Oimpany Name
7c.Type of disinfectant used: J7Ce.
2.Well Constraetion Permit II:
Luc at applicable nil perwar pc Camp'.Sore.Variance.Neaten.ere)Ifknown 7 c z
7d.Amount of disinfectant used:
3,Well use(cheeltwe0 ate): '
Water Supply Well: - 7c.Sealing materials used(check all that apply):
°Agricultural . OM icipaVPublic ° Neat Cement Grout O Berdanite Chips or pd(s
OGeothamol(Heatirtgtreoling Supply) iResidential Water Supply(single) 0 Sand Cement Grout °thy Clay❑IrdusvraVCemmmejnl o )
g eruppy(sared) (rh� Gu
Olrtigation 0 Specialty Grout 0 Gravel
Non-Water Supply{Yell:
-Injection 0 Bentonite Slurry 0 Other(explain octet 70
°Recovery
Injection W I: •.. 7f.For each material selected above,provide amount of materials mot
°Aquifer Recharge °Groundwater Remedintion 9�Z
°Aquifer Storage and Recovery °Salinity Barrier ..
°Aquifer Tat OStonmvatet Drainage
°Experimrnral Technology °Subsidence Control 7g.Provide a inlet description of the abandonment prwrdare
OGeothenmal(Closed Loop) ' °Tracer
°Geothmnal(Heating/Cooling Return) °Other(explain under 7g) nr �✓t70.4//S Al /15 L� 0u 1- “Jaime
// "�/// CliAnnnFr ( lLA., 17'1 e_onteek_.-E'aWiTiSl
J.Datewell(s)abandoned: rC�'g ( U. /(?e C� :50P-V'D1t JB,✓10✓e
/7 (
S3'7 .,��K Ste Well location: 015 //%o nor ✓1 f+.d?A}G�r )
FanhtyK3wwNUaw Facility ma cifq,plhable) '
8.Certification:
,3ie87 S Me. fh Nov r /nil; C." z BESb L
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6 Phytim)Occident,Cty.and Zip Signature o�fed eContrsnor or WellOma Oae
a4Q
By signing this farm, I hereby and that the wills) s y firer!)dicayabled en
Coup Parcel fdcnti0cmion No.(PIN) accordance nvlih ISA)(CAC OZC.0100 or 2C.0200 Wdd^—,nsm y„.J„-
Sb.Latitude and longitude In degrralmlautnJSecon0s or decimal degrees: °rrddmra copy of this record has been provided to the half oaaar
Of wen field„®Wiens ia sul0eiatl)
P.Site diagram or additional well details.
33:62 Ogg.30 N '81 r /3 9 7/y3 W You may use the back of this page to provide udduianl well Site dab or wol
abandonment details. You may also attach edditionl pally if necessary
CONSTRUCTION DEMOS OF WELLS)BEING ABANDONED SUBM1T1tL INSfR(I()TIaNS
Amer:all csuaaalat reetn1()(ardlobto. For multiple Infadlon or non-warer supply
nib ONLY with laemane ermnmeito,r'obaMmmmenr.you ten=emit one form 10e.for All Wells: Submit this torn within 30 drys of
abandonment to the follo or well
6a.Well ma: t'Aeg:
Q Division of Water Reesourees,laforavttoo Ptoa -g Vaa,
6b.Total well depth: 3... (It) 117 Atail Service Center,Raleigh,NC27699-1617
�,�1 LOb.For Injection Wells: fn addition to sending the farm to the o ape
6e.Aortbdedlameter. f(/ On-) above,also submit one copy of this form with,30 days of completion of wen
. ,/ abandonment to the following:
rid.Water Intl below ground surface: 2' (fLl Division of Water Resources,Underground fa)eetion Cantrd Preps-.
•1636 Moll Service Center,Raleigh,N°278994636
&.Crater aria=length(II known): (R) hoe.for Water Sanely&Injection Wells: In addition te aesdisg the fora m
the address(es) above,ralso submit one Copy of tin form within 30 days of
•
completion of well abandonment to the county health department of the canary
6f.loner casing/tubing length(if known): (IL) w+fim abandoned.
(thane length Or linowo): (B.)