Well Abandonment Record Form

10 WELL ABANDONMENT RECORD For Internal Use ONLY This form can be used for single or multiple wells 1 Well Contractor Information WELL ABANDONMENT DETAILS 7a Number of wells being abandoned For multiple injection or non - water supply wells ONLY with the same Well Contractor Name or well owner personally abandoning well on his her property construction abandonment , you can submit one form 7b Approximate volume of water remaining in well s gal NC Well Contractor Certification Number FOR WATER SUPPLY WELLS ONLY Company Name 7c Type of disinfectant used 2 Well Construction Permit # List all applicable well permits ie County , State , Variance , Injection , etc if known 7d Amount of disinfectant used 3 Well use check well use 7e Sealing materials used check all that apply Water Supply Well ? Neat Cement Grout ? Bentonite Chips or Pellets ? Agricultural ? Municipal Public ? Sand Cement Grout ? Dry Clay ? Geothermal Heating Cooling Supply ? Residential Water Supply single ? Concrete Grout ? Drill Cuttings ? Industrial Commercial ? Residential Water Supply shared ? Specialty Grout ? Gravel ? Irrigation Non - Water Supply Well ? Bentonite Slurry ? Other explain under 7g ? Monitoring ? Recovery 7f For each material selected above , provide amount of materials used Injection Well ? Aquifer Recharge ? Groundwater Remediation ? Aquifer Storage and Recovery ? Salinity Barrier ? Aquifer Test ? Stormwater Drainage ? Experimental Technology ? Subsidence Control 7g Provide a brief description of the abandonment procedure ? Geothermal Closed Loop ? Tracer ? Geothermal Heating Cooling Return ? Other explain under 7g 4 Date well s abandoned 5a Well location 8 Certification Facility Owner Name Facility ID # if applicable Signature of Certified Well Contractor or Well Owner Date Physical Address , City , and Zip By signing this form , I hereby certify that the well s was were abandoned in accordance with 15A NCAC 02C 0100 or 2C 0200 Well Construction Standards County Parcel Identification No PIN 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 You may use the back of this page to provide additional well site details or well N W abandonment details You may also attach additional pages if necessary CONSTRUCTION DETAILS OF WELL S BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record s if available For multiple injection or non - water supply wells ONLY with the same construction abandonment , you can submit one form 10a For All Wells Submit this form within 30 days of completion of well abandonment to the following 6a Well ID # Division of Water Resources , Information Processing Unit , 1617 Mail Service Center , Raleigh , NC 27699 - 1617 6b Total well depth ft 10b For Injection Wells In addition to sending the form 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 ft 1636 Mail Service Center , Raleigh , NC 27699 - 1636 10c For Water Supply & Injection 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 where abandoned 6f Inner casing tubing length if known ft 6g Screen length if known ft Form GW - 30 North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013Page