HomeMy WebLinkAboutWELL-12-2019-126551.TIF WELL ABANDONMENT RECORD For Internal Use ONLY:
I.Well Contractor Information: %Vhl 1.ABANDONMENT I)!•rAI Lia,
pi� s
( rival 10• ' f/j' j 7a.Itor Geoprohe/llf r or Closed-Loop Geothermal Wells having the same
Well Commetnr Nthrwtot well Owner pereorwliy atwudadaa Well on hbitei Ovumty), well conau'uction/depth,anlY I CW40 is needed Indicate TOTALN14MB2it of
wells abandoned; . .. �: •
WellContm¢MrCxmdeminn Number ( 70.Approximate volume of Water remaining lit well(s): RO (gal.)
r(1 A'W�L /]nn1 }� /j FOR WA'I'ER'SUri'LY WELLS ONLY:+ry �f'j,(
Company Name
��st�rddd///tf� WW// .^, -+ J 165 1 1 ``
/� Q //r'� 7e.Type of disinfectant used:
2.Well Construction Permit b�.,P Al—J. L_(O(I.C5.'
that all apptwable rill tro&ntetton priority d.r, OIL,C:+unty..crate Vurinure.etc.)(/t WHO 3j5
7d.Antonin of disinfectant used:..
3.Well use(check well use):
Water Supply Welk 7e:Sealing materials used(check all that apply):
{BAgnculmral QM idipnl/Public r., :Neat Cement Grout i 'jg„(Bentonite Chips orVeneta
OGeoihermal(fdeathngfConling Supply) ily.esidential Winter Supply(single) 41 Sand Cement Grout 0 Dry Clay
Olndusirial/Commereiaf OResidential Water Supply(shored) , 0 Concrete Gout. 0 Drill Cuttings. .
°I rigation `'O Specially Grout O Gravel •.,f
Non-Water Supply Well: O Bentonite Slurry 0 Other(explain under 7g)
°Monitoring OReenvery
Injection Well: 7f. For each material selected• wove,providej amount of materials used:
°.Aquifer Recharge ❑Groundwater Remediation O4 J,t, s.
OAquiferThstuge and Recovery °Salinity Barrier g I 0 1 , /A / Pt+LI1 OA niter 7L•st °StomnwAler Drainage • . j� bv/�'v�G 5:-,
°Experimental Technology °Subsidence Control
7g.Provide a brief description of the abandonment proeeduyyeo
oGeetherntai(Clmeed Loop) OTracel J' i k J C / L rx f Lt.
�d+4)
OGeotbermal flica(ingJCooling Return) ❑Other(explain under 7g) Gf/� 01 y� `T.L a( ,f /�
Q///�/�1 5 r4i(Ar /0�t Ay i yiz.h , .P
4.Date well(s)abandoned:!t ( tY a./ e �/
jSSit.Well ffloocfattionn::ic /(e -(///,e•(//�//
Facility/Owner Name Facility!Oft(if applicable). H.Certification:
`11c�p L n)brt 4 et4 Rd ? Dc v `` _ �-_ a�}/s(21
Phhyyc'cccalallKA dr
op..lily,anti Lip Signature ofCepihed Well Contractor r Well Owner D
` . Q 1.1) By signing this furor, I hereby certify that the went's) war(were) abandoned in
County Parcel idcntificaiion No.(PIN) accordance with 15AA'CAC 02C,0100 or 2C 02001Yell Cuostntction Standards
and that a copy of this retard has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one Belong is sufficient) 9.Site diagram or additional well details:.
N )Y You may use the back of this page to provide additional well site details or watt
abandonment details, You may aisoattaahadditional pages ifneeesSaty, i.
CON;STRlJ fo `pETAILS OF WF,LL(S)UEING ABANDONED SI)EMITTAL INS'I'RUGTIONS
oath ueBcanttraellmnweardte)ifaval/able.Firma/lap ein%geitr#t ornun•rmteryupply wellya
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ONLY with the sgmeraisrpxl7nnla6andonne'aq you can xnhgR oi7ditu•ni' IOa, For All Wells: Submit this form within 30 days of completion'of well
6a.Well IDN: abandonment to the following:
r ,/A Division of Water Resources,Information Processing Unit,
6b.Total well dept•se Y - 0% l� (fi.) 1617 Mail Service Center,Raleigh,NC 2 7 699-1 6 17
6 1/ 10b.For Zniectoa WehI : In addition to sending the form to the address in 10a
6c.Borehole diameter. (in.) ohm/C.also submit one copy of this 1'tstm within 30 days of completion of well
abotidunittent to the fallowing;
pn Division Of Water Resoutces,Un round Itijceton Control Proram,
6d.Water level belotvgronnd Surface: (is {rt.) E.
1636 Mull Servtee Center,Raleigh,NC 27699-1636
QQ I
tie.Outer easing length(if known): GG (ft.) IOc.For Water Saintly S Injection Welly In addition to sending the form to the
addfcss(os)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
bf,Inner casing/tubing length(if known): kilt
(ft.) abandoned.
fig.Screen length Ofknpuyn ; Pik-r` (ft;)
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