Rowan_Well Abandonment_20230104

WELL.ABANDONMENT RECORD
For internal Use ONLY:
I.Well Contractor Information:
WELL ABANDONMENT DETAILS
NEILL PARDUE
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-k is needed. Indicate TOTAL NUMBER of
2609A wells abandoned: i
NC Well ContractorCenification Number 7b.Approximate volume of water'remaining in well(s): (gal.)
AIR DRILLING INC FOR WATER SUPPLY WELLS ONLY:
Company Nmnc
2.Well Construction Permit#:
366288-2 7c.Type of disinfectant used: HTH
List all applicable well construction permits(i.e.UIC,Comuy,State,Variance,etc.)ijknowo 2 CUPS
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
PP Y):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothertal(Heating/Cooling Supply) i 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:
ex
❑ Bentonite Slurry ❑ Other p lain under 7
❑Monitoring ❑Recovery (explain g)
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remccliation 150 LBS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7g) POURED 150 LBS BENTONITE CHIPS
2-10-2022 ;
4.Date well(s)abandoned: V
5a.Well location:
DARRIN PASCHAL
Facility/Owner Name Facility ID#(ifapplicable) _ 8.Certific • r,;p r' J UDi�
130 WHITE RD, SALISBURY,N.C. 28147 2-10-2022
Physical Address,City,and Zip Si tatum of Certified Well Contractor or Well Own Date
ROWAN 770033
Count By signing this form, I hereby certify that the well(s) tvas(were)abandoned in
y Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 oi-2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient)
35° 38.536 9.Site diagram or additional well details:
N 80° 38.109 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(SI BEING ABANDONED
Attach well constructionrecord(s)favallable.Pornmhiplehjeclionornon-walersupplytvells SUBMITTAL INSTRUCTIONS
ONLY with the same construction/abandonment,yoi can submit ate form.
10a. 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,
Gb.Total well depth: 1�� (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Gc.Borehole diameter: 3 10b.For Iniection Wells: In addition to sending the form to the address in 10a
(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: (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&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
Gf.Inner casing/tubing length(if known): (ft,) abandoned.
Gg.Screen length(if known):
Form G W-30
North Carolina Department of Environmental Quality-Division of Water Resources!: I Revised 2-22-2016