HomeMy WebLinkAboutWELL-04-2022-170272.TIF WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor information: WELL ABANDONMENT DETAILS
Je 4 (6 e 7a.Number of wells being abandoned: i
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple infection or non-water supply wells ONLY with the saute
construction/abandonment.you can subtntl one lieut.
NC Well Contractor Certif cation Number 7b.Approximate volume of water remaining In well(s): Lib S
L` /lot.M..0 wt I FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: C f c i1et A�
2.Well Construction Permit#:
List all applicable urn permits(i.e.County.State.Variance.Irrlecriows ere.)ifbasun p'2
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 C: Neat Cement Grout 0 Bentonite Chips or Pellets
:Geothermal(Heating/Cooling Supply) lidesidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial :Residential Water Supply(shared) ■Concrete Grout 0 Drill Cuttings
:Irrigation Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
:Monitoring =Rccovcry
Injection Well: 7f.For each material selected above,provide amount of materials used:
:Aquifer Recharge -Groundwater Remedial ion S p USr pr4.f(r,As)
❑Aquifer Storage and Recovery Salinity Barrier rr
% ( i!•1.1 J
t 5)
:Aquifer Test =Stoumwatcr Drainage .W4 LJ14 -
:Experimental Technology :Subsidence Control 7g.Provide a brief description of the abandonment procedure:
:Geothermal(Closed Loop) Tracer �jy r
:Geothermal(Heating'Cooline Rentm) Other(explain under
Q 3 I e� «f' ``fie
CO �"�4Scr C ur1C/YIt Fca 4 olp Ci AA J
v 4.Date well(s)abandoned: t
•t c.z t G�(p c-c.Oct ere
5a.11'ell location:
Facility:Owner Name Facility IN(if applicable) 8.Certification:
Q ta C 1-‘: ld... ,r t i� riot) c`7 -
Physical Address.City.and Zip Signnt o ifi Cell Contract r or 'ell Owner Date
Cc-biC'L tU IDA BY signing this ftr•rn, 1 hereby ecru/(•that the tvell(s; was/were)abandoned in
County Parcel Identification No.(PINT accordance with 15.4.VC:.,C 02C.0100 or?C.0200 Well Construction Standards
and that a cops'of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field.one fat long it sufficient) 9.Site diagram or additional well details:
G 'Ua 3 U 3 You may use the back of this page to provide additional well site details or well
w N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTiON DETAILS OF WELL(S)BEiNG ABANDONED $UBM1TTAL INSTRUCTIONS
Attach srcil construction rerurde.t if available. Fr,multiple injection or'ion-water supple
wells ONLY with the came c•m,rmrction/obandenmenr,roll can mama one form. 10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well iDU:
Division of Water Resources.Information Processing Unit.
6b.Total well depth: (ft.)
1617 Mail Service Center,Raleigh.NC 27699-1617
10b.For Injection Wells: In addition to sending the firm to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 36' (ft.) 1636 Mall Service Center,Raleigh,NC 27699-1636
O 10c.For Water Sunuly& infection Wells: In addition to sending the Form to
6e.Outer casing length(if known): (ft.) the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
A where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
A.
6g.Screen length(if known): (ft.)
Foam GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013