HomeMy WebLinkAboutWELL-07-2016-074950.TIF Aug 22 16 11:44a Advanced Well Drilling, L 8282412445 p.2
WELL ABANDONMENT RECORD I
ParInternal-Um ONLY: '
This form can be used.Cur single or multiple wells '
I
I.Wen Contractor Information: WELL ABANDONMENT DETAILS {
le.Number of wens luting
I. abandoned: `
\Veil Coctmcior Name Cur well tomer personally abandoning well on Mach property) For multiple bgecrum, or arm-'rcdrr supply ~'ells ONLY with the same
cornlnimion/atondonmenli you can submit orefame,
(3-232_ , 1 (gat)
7b.Approximate volume of water remaining in well(s): g
NC Well Conn-actor Certification Number I
/94 a/p�Ce _! It i) -✓!yl 1 // 43 I Z C.. FOR WATER SUP PLY WELLS ONLY: l
CompanyName Cl 1J//,, d/ /r� 7 / /JA 7c.Type of disinfectalit used: �'-)%/ 1
2.Well Construction Permit W. W t- )11'0 /-2-e i!p o.77 Se. I �.t
Lin all applicable nett permits(i.e.Cwmty.&ate, Variance.It)ectian,ae.)i/:noten 7d.Aotountof disinfectant used: c�""''�� I b $
3.Well use(.faat welt orae):
Water Supply Well: 7e.Sealing materials used(check all that apply):
11Agricu7N21 DMuunicipa}(Public C Neat Cement Grout; Bentonite Chips or Pallas
°Geothermal(lieatiog/Cooling Supply) Ettfrocidential Water Supply(single) 0 Sand Cement Grout; ❑ Dry Clay
Clndusziat'Comrnudal °Residential Water Supply(shared) •tancrcle Grout 0 Drill Cuttings
°Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry C Other(explain under 7g)
0Stonitoring GRecovery.
Injection Well: 7E For melt material Selected above,provide amount of materials used:
°Aquifer Recharge °Groundwater Remediation V 8 p J b s
°Aquifer Storage ant Recovery l7salinity Sorrier
°Aquifer Test OStonnwnter Drainage .
°Experimental Technology °Subsidence Control 7g.Provide a..bb/r�ief description of the abandonmentprocedure:
OGeothmmmal(Closed Loop) °Traces MS y L W n s f f 4 'f 1/ S'
OGeotheral(Ileating/Cooling Return) OOdser(explain under-7g)) 5
I�Nr�a- C0nere"lc, Uiat. )0 >.-7/ rt
l{ri
4.Data weu(s)abandnned: 7-e. 7-aDlt, g okra d. / Irl x i81 jo>4s ort, 9 oe
r
Sa.Well location: o' Ce ee
ifAtari), Sfl.ttt; Ot _ •
B.Certifimriom
bnellylOwrer Name - Facility Ent(if applicable)
/ /�
f0.,. V k Drrf�.,1 !!s load 2-6 I>, /.es' �/ - 2 7�t/6
C and Zi immure of ' s •el antraaar Veil Owner Dare
Physical Adams, ay, p p
C Cede,lib G. �/j ie 2. 9 V 3 OD cc L7 SI)signing ibis farm I hereby comfy that the well(s) was(mere) abandoned in
County Parcel klemiEariun No.(PIN) accordance turtle/SA NCACO2C.0100 or 2C.0200 Well Construction Standards
and Ihca a copy vi this record has been prodded re the well owner.
Sb.Latitude and longitude in dt rees/mineteslseconds or Marna]degrees:
(ifwel tele.one h flank issunlciem) 9.Site diagram or additional well details:
4)37,7 -42.2,
(�y ' 1 �5 r N (1D a 2'af3 D '
You may use the back of this page to provide additional welt site details or welt
5 W' ebandua:nent details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
arum well cnnsrruction record(4 if ovoilofte- For''minpte inject:on or nun-avatar sPph
exits ONLY uirh the sane rnn+tiucuoNobonrnnmeat.you Con submit one fora 10n. Fpr Al Welts: Suomi' this lam within 30 days of completion at veli
abandonment on the following:
6a.Well ID#:
�/ / Division of Water Resources,Information Processing Unit,
6b.Total well depth: / CI (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
IUD.For InIcahn'Wells: In addition to sending the Corm to the address in On
above.,also submit one copy of this form within 30 days of completion of well
6r-Borehole diameter. 2 (In.) abandonment to the following:
Division of Water Resources,Undergroundinjection Control Program,
6d Water level below ground surface: / (R) 1636.Mail Service Center,Raleigh,NC 27699-1636
Gen Nina-P-1 (IL) For Water Sply&Iniection Welts: In addition to sending the form to
6e.Outer casing length(if known): up
the address(es) above, also submit one copy of this form within 30 days of
C i completion Minuet!abandonment to the county health department of the county
(R) where abandoned.
6E Inner casingitutuug length(if/MOWE): O
on Scrci'u Icuxdr Oe knom ; ('t)
FormCW-30 Nonh Caroliu.Department of L'nvinenment and Natural lteaources-Division of Water Resources Revues August''au IS