Alamance_Well Abandonment_ (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3344-A - wells abandoned:ere
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.4 (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY: +, p+�{�
Company Name 7c.Type of disinfectant used: 7-�C �
2.Well Construction Permit#: N/A a==
List all applicable well constnrction permits(i.e.UIC,Comity,State,Variance,etc)ifkno+wt MAY 3 0 2022
7d.Amount of disinfectant used:
3.Well use(check well use):
inforcrtsicn Pr•c3;►3ing Unit
Water Supply Well: 7e.Sealing materials used(check all that apply): D14/Q/6QG
❑Agricultural ❑Municipal/Public 19 Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
e M onitoring ❑Recovery
Injection Well:. 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite - 25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Neat cement - 40 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips from 20-5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Pour neat cement from 5' bgs to ground surface
4.Date well(s)abandoned: 5/4/2022
5a.Well location:
Former Express 552 0-023879
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1845 North Church Street / 5.19.2022
Physical Address,City,an Zip Signature ofCertifiedV Contractor or Well Owner Date
Burlington AIM, 139749 By signing this.jornr, I hereby certi/i that the uell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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:
(ifwell field,one[at/long is sufficient) 9.Site diagram or additional well details:
36.095071 N -79.406368 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attachivelicof+stractionrecord(s)ijavailable. Fornadtipleitljectia+ornotru•atersapp(vu•e/ls
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this fonu within 30 days of completion of well
6a.Well iD#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
(ft.) Raleigh,
6b.Total well depth: .0 20 1617 Mail Service Center Raleig NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (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: 12.78 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A A) 10c.For Water Suptily&Iniection Wells: In addition to sending the form to 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
6f.Inner casing/tubing length(if known): 5 (ft.) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016