Yadkin_Well Abandonment_20220823

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on Iris/her property) For multiple injection or non-)voter supply the//s ONLY with the same
construction/abandonment,you can submit one form.
C - 4421
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'0
(gal.)
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: r a' f�:-^•a. r —
2.Well Construction Permit#:
List all applicable hell construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
RIO!r
3.Well use(check well use):
7e.Sealing materials used(chdClf�tlydKAta�p7jt).C;:w.,;', UR;a
Water Supply Well: 9
❑Agricultural ❑Municipal/Public
❑Neat Cement Grout Dwt€3Cia't(xiite 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: 21 Bentonite Slurry ❑Other(explain under 7g)
ZMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 8.0 GALLONS
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑)xperimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
d.Date well(s)abandoned: 06/04/22
Sa.Well location:
WEST YADKINVILLE GROCERY
Facility/Owner Name Facility ID#(if applicable)
$•Certification:
4420 OLD US 421 HAMPTONVILLE 27020 ""`"` 06/15/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
YADKIN By signing this form, I hereby certify that the tvell(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 lattlong is sufficient) 9.Site diagram or additional well details:
36e 07' 19.36" 800 47' 12.52" 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 constructiontabandontnt nt,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
49.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
37.0 Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
loc. For Water Supply&Iniection 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013