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1.Well Contractor Information: ---
WE.LI,AUA,NBONMEN['I/F.T „I„IAti
Alfred Kiesling Jr
la,For Geoprohe/DPT or Closed-hoop Geothermal Wells having the some
Well l omronm Name(or well owner prttamlly abandomny cell an hi%h er property) well construcuon.'depth,only I GW'.3(1 is needed Indicate TOTAL NUMBER of
3266-A wells abandoned t -.
NC Well Contracts i:enifKauon Number 7b,Approximate volume of water remaining In well(.):
B & K WeLI Drilling Inc ' �'I''
FOR WATER SUPPLY WELLS ONLY:
Compass Name Chlorine
Tc.Type of disinfectant used:
2.Well Construction Permit#: D 114/... ! e y
List pU uppUcablr well cunirrurr,on S_3c eec)_-
permas(i r U(C,County,State Variance,etc)ifknrwn
7d.Amount of dtslnfcctant used: $'b Vm C r.cJ
3.Well use(check well use):
Water Supply Well:
7e.Sealing materials used(check all that apply):
°Agricultural CMumci al'Public
P tri;cat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Itcaang'Cooling Supply) IMRcsidential Water Supply(single) ❑Sand Cement Grout 0 Dry Clay
Olndustrial.Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑lin',anon
Non-\Pater Supply Well: C1 Specialty Grout 0 Gravel
UManitoring 0 Bentonite Slurry 0 Other(explain under 7g)
Injection Well: ❑Recovery
OAqui[cr Recharge 7L For each material selected above,provide amount of materials used:
OGroundwatei Rcnresliation
❑Aquifer Storage and Recovery OSalinity barrier
°Aquifer Test CStormwaterr Drainage .2 �AS o Qom ck�,I
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothtrmsl(Closed Loop) ❑Tracer
❑Geothermal(Beano .Conlin Return) ❑Other ex lain under 7 r //
) /err `Ct�/ cir�d/ t4,J!`{v
4.Date well(s)abandoned;�11/5V/2-3
So.Well location: e
FFocduyrpwMr game 11 Facility INOf applicable) 8.Certification:
4 74/ L.Her . a w,tx,+.?..d
Physical Address,City,and Zip
_ ..�/V '�'s
/] 4ruoccnirnr ,ettr
Dare
aka W.14 Ct
t3697Dot594'd 7
County By signing this form, I hereby certi rut the well(s) was(were)abandoned in
Parcel identification No.(PIN) accordance with ISA,A'CAC 02C.0lO0 or?C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of rho record has been provided to the weir/owner.
(dwell field,onc la ionp is sufficient)
9.Site diagram or additional well details;
N %V You may use the back of this page to provide additional well site details or well
abandonment details, You may also attach additional pages if necessary,
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
Attach melconstruction rruud(strfavatlable.For multiple inrrwunor non.UVler supply wrnls aS taw 17"fAL INSTRUCTIONS
ONLY weth the same construcnonlabandonme•nt,you can submit one from
10a, For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: OW 1617 Mall Service Center,Raleigh,NC 27699-1617
1111.For Iniection %Veils: In addition to sending the form to the address in IOa
6c.Borehole diameter: LPN (In.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: D (ft.) Dirlsioo of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 2 7699-1 63 6
6e.Outer casing length(if known): (n,) I Oe.For 1ti'atvr Supple&Infection Wells: In addition to sending the form to the
address(es)abuse.also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
61.Inner easing'tubing length(if known): (ft.) abandoned
6g.Screen length(if known): (to
Form GW-30 North Carolina Depanrrtent of Ern ironmcnul Quality-Division of Water Resources
Revved 2-22-2016