Iredell_Well Abandonment_ (4)

WELL ABANDONMENT RE CORD
For Internal Use ONLY: f
I.W011'Contraclor Information: WELL.A13AN'D0NMGINT DETAILS
RANDY OWNBEY
7a.For Ceoprolm/DP'i'or Closed-L,'•otip Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/lier property) well construction/depth,only I GW-30 is needed, Indicate'rOTAL NUMBEI; of
3214A wells abandoned: I
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NC Well Contractor CertiRcation Number 7b.Approximate volume of water>emaining in well(s): (gal.)
AIR DRILLING INC FOR WATRA SUPPLY WELLS ONLY
C'umpony Name
7e.'Iypeafdisitareetaptused: HTH
2.Well Construction Permit ff:_OSW_P-20224878
List tilt applicable me/1 constr•uctiarr permils•(i.c /C,_. U Coarr0•,Stare, Variance,etc.)jl,•norrtr 2 CUPS
7t1,Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(clieck all that apply):
❑Agricultural QMunicipal/Public ❑ Neat Cement Grout ❑ Bentonitc Chips or Pellets
❑Geothermal(I-Icating/Cooling Supply) gResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑ Drill Cuttings
nirri*ation 0 Specialty Grout t7 Gravel
Non-Water Supply Well; ❑ Bentonite Slurry ❑ Other(explain under 7g)
ONloniloring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Reniediation 5 YDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwaler Drainage
❑Experimental Technology ❑Subsidence Control
❑Geotlierrmtal(Closed Loop) [:]Tracer•
7g.Provide.a brief description of the!abandonment procedure:❑Geothermal(bleating/Cooling Recant) ❑Other(explain under 7g) POURED 5 YDS CONCRETE
4.Dale well(s)abandoned: 11'1 6-2022
511.Well location:
KEVIN ZIRKLE "
1. �M r-p—_Zvcv
facility/OwnerNane Facility IDII(it'applicable) 8.Certifieat'
1155 SHINNVILLE RD,CLEVELAND, N.C. 27013 �tPrac**VI',)Urfa
D QlT*—'1 6-2022
Physical Address,City,and Zip Signnt c of Ccrtif Well onirac!or or wrier Date
IREDELL 4760939503
By signing Ibis torn!, !hereby cerlifj�that the well(s) wrrs (were) abandoned ill
County Parcel Identification No.(PIN) accordance with 1511 NCAC 02C.01,00 or 2C.0200 ell Co!siri(crion Standards
told that a copy of this•record has been provided to the well owner,
Sb.Latitude and longitude in degrees/minttes/seconds or decimal degrees:
(ifwcll tidal,one Int/long is sufficient) 9.Site diagram or additional well details:
350 40.169 N 80° 47.083 W You may use Elio back of this page to provide additional well she details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED
annr•h irc11 con.ru anion rec•ru•d(.+)if'aivnilrrGle. Favmrltiple inJectinn orvu=mrrrer•.,•upply wells SUBMITTAL INSTRUCTIONS
ONLY with the some coast ectiordabnadouncrrl,pod can subunit rare fb,•ur.
10a, For All Wells; Submit this form within 30 days of completion of well
fist.Well IDff: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth; 35 —(ft.) 1617 Mail Service Centel-,Raleigh,NC 27699-1617
101), For Injection Wells; In addition to sending the f'o•m to the address in Ilia
6c.Borehole diameter-: 24 (in) above, also submit one copy of this,form within 30 days of completion of well
abandonment to the following:
6th Water level below ground surface: (1't.) Division of Water Resources,Uiider•grotn d injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) 1 Oc.for Water Supply&Injection I'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): (ft.) abandoned.
• r I
6g.Screen length(if known): A)
Form G W-30 North Carolina Department of Environmcntnl Quality-Division of W ater Resources Revisal 2.22.2016
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