Alamance_Well Abandonment_20230515

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Russell James Turner 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning%veil on his/her property) well construction/depth,onl�1 GW-30 is needed. Indicate TOTAL NUMBER of
2448-A wells abandoned:Rmr't
NC Well Contractor Certification Number 7b.Approximate volume of water,,remaining in well(s):
R.J. Turner Well and Pump, LLC. FOR WATER SUPPLY WELLS ONLY: ,t�.
Company S I.�,q_
p y Name Tax Ma 3—�8-75 7c.Type of disinfectant used: ���9
2.Well Construction Permit#: p MAY 7
List all applicable n•ell constriction permits(i.e.UIC.County,State,Pariance,etc.)ifknouv L o23
7d.Amount of disinfectant used:
3.Well use(check well use): r- RYit-
Water Supply Well: 7e.Sealing materials used(check all that apply): ov
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) S Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1/4 Yard of sand cement grout
❑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:
Cut well casing and well grout off 3 ft.below ground level for each well.
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under 7g)
Backed cement truck to wells and poured sand/cement grout
4.Date well(s)abandoned: 04/11/2023 in each well till each well was completely full from bottom to top
Sa.Well location: of wells with sand cement grout mix.
MPV SBR Investors III LLC
Facility/Owner Name Facility ID (ifapplicable) 8.Certification:
571 Huffman Mill Rd., Burlington, N.C. 27215 ,/ �i� � ��� 1-- c )6.23
Physical Address,City,and Zip signature of Certil' Well Contractor or Well Owner Date
Alamance 173295
By signing this fotTn,1/terebv certify[liar the x•el!(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A 1VCAC 02C.0100 or 2C.0200 Well Constniction Standards
and their a copy of this record has been provided to the%yell owner.
5b.Latitude and longitude is degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.07487 N -79.49134 `,it You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
dttachitel!constrictionrecmd(s)ifarailahle.Farvmdtipleinjectionornon-watersupplvisells
OA'LY pith the same cottsavctiotdahmidmtrtietit,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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 27 A) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection 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:
6d.Water level below ground surface:25 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unknown (ft.) 10c.For Water Suouly&Iniecton 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): no Inner (ft) abandoned.
6g.Screen length Of known):
Form GW-30 North Carolina Department of Environmental Quality-Division of\Pater Resotrrccs Revised 2-22-2016

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