HomeMy WebLinkAboutWELL-01-2022-163426.TIF ' I1, (,IIV 7 • JU /si
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AliANDO r1YlL'1f 1 .IC.F�COIZD Forinterne(VuONI.Y. f
1.Weli Caattaetvr Win motion: WELL ABANDONfJ NI s. IS
Lift �4 7a.For CeuprabtfDPT or Cluatd-Loop Geothermal We1b having rho Berne
Wet Cornetoe N.r VFW welly aba.d ir.r�well on hid6er prupar y) well conairuceiorrldepth,only I G/•J0 is needed lndirate TOTAL tfl)MHER of
Walls abandoned;
NC WelComasor CalibrationNootbtu �j' 7b Appro:iara'e reliant el wain remaio;ar to avell(a),
_4.jf19h I tafGIL �' Aar FOR WATER SUPPLY WELLS ONLY:
C011 ay N . (�l 1 o rii c.
f )q a 7a Type of disinfectant used:
t Well Cotutrrctlatt Permit p: I tD 3 g
Leer rrtt'coca*
vale twra'r-J Dual'$(Si.UIC;C'oaepc Sm'S rar4".c.'"Si irk.'""
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7d..�ana1 Of Clink/tacittiled: `�0
3.Well rat(check well rat):
Water Supply Will: 7c.Sealing materials used(check all that apply
0Agricuitural DMunrripaVPublic 0 Neat Cement Grout e tonite Chips or Pellets
❑Geothermal(Heatlnt/Couling Supply) LiiCgsrdentral Water Supply(single) 0 Sand Cement Grout 7 Dry Clay
❑InductnoI/Commcial °Residential Water Supply(shared) tbncrete Grout 0 Drill Cuttings
°irrigatim , 03 Specialty Grout 0 Gravel
Non-Water Supply Well! 0 Bentonite Shiny 0 Other(explain under 7g)
Ohlonitoririg ❑Recovery
IeJeci1om Will;
Cn 7f.Per oath material'elected above,provide amount of materials wed;
❑Aquifer Recharge OoundwaterRemedienon `1 6 5 Q1 hlOt?iTfi C�Ips
❑Aquifer Storage and Recovery °Salinity Denier / L
°Aquifer Teat °S farm wetreDrarrage 2 7 Ydgc � Cox -T(.
rpcnmcrinal 1 chzsolap ❑Snbsiduice Control 7g,Provide a brief description of the abandonment procedure:
F ❑t3°Geothermal(Closed loop) Dirseer I / l 1 // f
❑rsoue}ermal(HutiryJC'c piing Return) ❑Other(explain under 7g) GJL>If Lcl a%��rotti , j (J ( I/sr��1C•
u 'hnl11//i/ rr f1gnn�f6 ay1 /n,
4.Date wants)abeadaued: I /10I.2.2 lizz77 eit? f fix/ n1 d i,p i.A `�r C/G7r
SR.WW location:
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;A'fl1C Jir,rru.r
FsadityrOarrorNw Faoiity IN(if makable) S.Ccrtiflraa(unt 4G ii
, L�,asua rl 1. L
r-' L ?�G7,3 d 'j K _'//lf„�.1
Ptcrska1 Adams.City.aryl Zip S wane of C Well Co or Well Owmer tt
wa 1 th0. 116 14)30J.ga q 3 By rlam,s(ha-fana l hereby cerrJr that the lrcll(s)war(Seer e)abandoned hr
Cooney Ferrel ldeonn cal i a No (PIN) accordance wtrh 1 Sa NGIC 02C 0100 or 2C 0200 Well Corocrwcrron Standards
Sb.tof1fods and tantta,ada to degreestrainuteilreeonde or decimal leercrs: and Oar a copy of Ns record has beereprpr(dtC to Jet trait turner.
Orwell dill,one Won/it tt.a8e. ii} 9.Site diagram or additional well details]
ill* N A W You may use the beck of this page to provide additionat well site detaila or well
i abandonment details. You may also attach nridiuonel pogcs if necessary.
is coNmucyf(IN DETAILS OP weal$)B)=ING ABANUOMI;:13
�iws•/rwdtrv+lnvr.e' nreerd(,)deeaitoola.Fee maerolornytcriun0enon-nwrer,wppIyurtb S(1Sf1f1TTALINSTRl'CT1ChY�
ox/t.+rl.ares..aa►-A,r^`a/+an^u,,no.,,a,,ra e,.,,,a.ns..�ro.L M. for All Walks Submit this form wither 30 days of completion of well
6a,Well 1DO: f/tt abandonment to the following
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1 ,/� Divlaioo of Water Resoaren,Informs]dos Pr arming Unit,
$ 6b 7ota1 tr+ll dep1A: LY!t 1 (t4) 1617 hull Service Center,Raleigh,NC Z7699-1617
lOb.For Infection Wells; In addition to sending the form to the addreus in ID.
Et.Barak.la diameter: (in,) above, also submit one co
py of this form within 30 days of completion of rvtU
abandonment In the following-
6d.Water level below:rood siwfare:—I al_ _(ft,) Dividoo of Water Rtsevrrer,Uadeteroomd 1aJeetlo■Con Ind Pro:rots,
/�t/ 1:36 Mail Service Center,Rakish,NC 27699-1636
tr.Oyler easing teottk(if lama); L y!4 (h,) l Ot,Far We let Sopptr&!nice tf Go Weill: In addition to sending the form to the
'1 rdduat(ea)above,also submit one ropy of this form within 30 days of completion
obi k /^^ of well abandonment to the county health department of the county where
cs
6f,turf da=1t ti length(inflows): !!7 (.) abandoned
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6t.Srroe band(tf known): _A (r)
?aria GW-30 Match Caroller Devitmaere of lerfirortrioiiii Q„egty•Division ofWie.e R+w.een '!..i
ttavitad 2.21-10I6