HomeMy WebLinkAboutWELL-12-2021-162675.TIF WELL ABAND ( ----------
for Internal l:cc U�I.1'•
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I.Well ontractor I p mation: WELL ABANDONMENT DETAILS furs
L_ [J IdtoddGur n 7a.For Geoprohe/DPT or Closed-Loop Geothermal Wells having the same
�Well Contractor Name(or well owner personally abandoning well on his/bet pmperty) well construction/depth,only l G s needed. Indicate TOTAL NUMBER of
40nL wells abandoned:
NC ell Contractor Certification Num 7b.Approximate volume of water remaining in well(s): 960 (gal.)
ffie} 2 �� � FOR WATER SUPPLY WELLS ONLY:
Company Name +�
7c.Type of disinfectant used: ("I IOf t<o1,t0D-r,.iJO� )
2.Weil Construction Permit N: 3( l 02,59 3(.0 2-0J
List all applicable well construction permits(i.e. UIC,County,State, Variance, etc.)if known d�
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) t Sand Cement Grout 0 Thy Clay
❑lndustrial/Commercial [Residential Water Supply(shared) 0 Concrete Grout 0 DrilI Cuttings
❑irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slu
rry 0 Other(explain under 7g)
GMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation S CI6 e,1?r,e 1,
❑Aquifer Storage and Recovery ❑Salinity Barrier "
C'Aquifer Test ❑Storrnwater Drainage
CErperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
0Geothermal(Heating)Cooling Return) ❑Other(explain under 7g) U i S Z)0(0., 5 i°-D'Q f - -t if L.,/t 'r II
CO-1 Cf 4 -1--e ate D) .I a/-s1,1-1 r/�es,v)
4.Date well(s)abandoned: �p t6 X I ,S- r 9' Gt � v-id i, ii ® (e
5a.Well location: 1
Facility/pwa Name Facility ID#(if applicable) 8.Certifieati
•111 (kA- 0,),12 00,41o04. Yl-c sit)./
P111teal ABdreae, try,and Zip Signs of Certified Well Contractor or Well Owner Date
6 -Cf.)_LAC3By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat./long is sufficient) 9.Site diagram or additional well details:
V 1 N S i,0(04`4 7l0 W 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 WELLfS1$EI)VG ABANDONED SUBMITTAL INSTRUCTIONS
Attach well conswctionrecord(s)ifavailable. For multiple Injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. I Os. For All Wells: Submit this farm within 30 days of completion of well
6a.Well ID#:
36 -?d 2-S rd 3 .--G abandonment to the following:
Division of Water Resources,Information Processing Unit,
t617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: U (ft.)
tub. For lulectiou Wdts: In addition to sending the form to the address in 10a
'�L) (In) above, also submit one copy of this tort within 30 days of completion of well
6a Borehole diameter: ahandonurent to the following:
Division or Water Reaourcea,Underground Injection Control Program,
bd Water level below ground surface: S (ft.) Division
null Service Center,Raleigh,NC 27699-1636
6e.Outer casing length Of known): AZ/It (ft,) IUc.Or Water Suuuly&lulactluu Wells: In addition to sending the forrtz to the
address(es)uhovo,also submit one copy of this tofu within 30 days of completion
/ of welln d ahandonntrnt Cu the county health department of the county where
6E tamer ca singitubing length(If known): t y�47 (ft.) abando ,
6g.Screen length Of known): ' "/4/44— (ft.)
Fo.rn ow-30 Noah Carolina t)ep noncom orlinvitvnn,cneat Qwilly-Division or Watsf ` Revised 2-22.2016