Robeson_Well Abandonment_20221028

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Ammons 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2035A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.5 (gal.)
EHC Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name H ochlorite Tablet
NA 7c.Type of disinfectant used: yp
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown 1.5 ounces
7d.Amount of disinfectant used:
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5 Ibs Portland Cement
❑Aquifer Storage and Recovery ❑Salinity Barrier
1 lb Bentonite Powder
❑Aquifer Test ❑StormwaterDrainage
❑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) Disconnected pump pipe from supply well and
cut off level with concrete floor in pump house.
4.Date well(s)abandoned: 1 0-24-2022 Disinfected well prior to slow pour of portland
5a.Well location: cement/bentonite powder.
Randall Hall NA
Facility/Owner Name Facility ID#(if applicable) 8.Certi'Feah
2104 Buie Philadelphus Rd 10-22-2022
Physical Address,City,and Zip Signature o Ce find Well Contractor or Well Owner Date
Robeson 935578372500
By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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: e
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
34.73535 N -79.14212 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
Attach well construction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#' Store Well abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 1.5 (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: 11.40 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Supply&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): NA (ft.) abandoned.
6g.Screen length(if known): U N (ft) E
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016