Iredell_Well Abandonment_20230104 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
CHAD HARTN ESS 7a.For Geoprobe/DPT or Closed lI-LIoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/lief property) well construction/depth,only 1 GW-30 is heeded. Indicate TOTAL NUMBER of
2901 A wells abandoned: I
' 1
NC Well Contractor Certification Number 7b.Approximate volume of wader remaining in well(s): (gal.)
AIR DRILLING INC
FOR WATER SUPPLY WELLS ONLY:
Company Name HT H
327633 7e.Type of disinfectant used:
2.Well Construction Permit#: i
List all applicable well construction permits(i.e.UIC,Cotmty,State, Variance,etc.)if known 2 CUPS
7d.Amount of disinfectant used:I
3.Well use(check well use):
i
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout N Bentonitc Chips or Pellets
❑Geothenmal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri gation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonitc Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7G For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 150 BAGS
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology, ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(HeatinClosed/Cool ❑Tracer POURED 150 BAGS BENTONITE CHIPS
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ff4 11.. t
a CC,R....-h `FS`tom,.12,
4.Date well(s)abandoned: 07-1 1—2022
_ JA►v 0 `� 2K3
5a.Well location:
RICK WILSON' Pyn!..A��--a Unil
Facility/Owner Name Facility 1D#(if applicable) C rtificat�n:
142 BALLEYCASTLE RDNOORESVILLEXC. 28117 -.�07-11-2022
Physical Address,City,and Zip Signature of Certified Well Contractor on Well Owner` ,.- Date
IREDELL 4614839781
County Parcel idcutification No.(PIN)
By signing lhis form, I hereby cerlfy,that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this racord has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 9.Site diagram or additional well details:
350 30.175 N 800 57.152 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
Allach well construction recorel(s)ifavailable. For mutldple byeetion at.moil-❑,alersl1pp1y wells
ONLY with the.same cacrtrucliott/abaadnumumt,you can submit one fornt.
IOa. For All Wells: Submit this form within 30 days of completion of well '
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: `58 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: f
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Ccnticr,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suoph'S Iniectiori 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.
I
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I
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division or Water Resources j Revised 2-22-2016

it
WELL ABANDONMENT RECORD For Internal Usc ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
CHAD HARTNESS f '
7a.For Geoprobe/DPT or Closed gLoop 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
2901 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water)remaining in well(s): (gal.)
AIR DRILLING I N C FOR WATER SUPPLY WELLS ONLY:
Company Name B'ENTONITE CHIPS
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown "1 20 LBS
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all'that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i, R Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) PResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout 1 ❑Drill Cuttings
❑hri 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 ❑GroundwaterRemediation 120 LBS
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer POURED 120LBS' BENTONITE CHIPS
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) _
08-16-2022 °`�6 t,
4.Date well(s)abandoned:
5a.Well location:
I'
MORGAN&PARKER BUILDERS IJ l'
Facility/Owner Name Facility ID#(if applicable) Cer ratio e7{a<Qi r' t3
117 RASPBERRY LANE, MOORESVILLE, N.C. 28117 I _ 708-16-2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Wcll Owner" Date
IREDELL ''
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 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 lat/]ong is sufficient) 9.Site diagram or additional wellidetails:
35 °30.071 N 80°56.330 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 1:
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupply wells
ONLY with the same constructio✓abandonment,you can submit one form.
10a. For All Wells: Submit this'form within 30 days of completion of well
6a.Well ID#• abandonment to the following:
i
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 60 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
; I
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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.
t � `
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016