Rowan_Well Abandonment_20230602 (4)

WELL ABANDONMENT RECORD Far lmernal Use ONLY.-
This form can be used for single or multiple wells
1,Well Contractor Information: WELL ABANDONMENT DETAILS
KENNY SARGENT 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-hater supply wells ONLY frith the some
A - 4226 cotisirtictiotr'abatctonnnent,you can subiritt 1 to form.
1
NC Well Contractor Certification Numberr
7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS'ONLY:
Company Name 7c.Type of disinfectant used:
2.'Well Construction Permit#:
l,tsi all applic•ahle irell construction pernins(i.e.Comity,State.Variance,etc.)1J'biowti
7d.Amount of disinfectant used:
3.Well use(check-well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Munici al/Public ❑ Neat Cement Grgin r -�.?, ❑ Bentonite Chips or Pellets
❑Geotherma GPo
l(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement ttt -�+.�'L7. p.r'�"O-br�Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout f t ff-- ❑ Drill Cuttings
❑Irrigation P Y
l7 S ecialt Grout JUIIN V � 2023❑ Gravel,
Non-Water Supply Well: El'Bentonite SlugLy;-;},-,:;-,•1 .� _ ❑ Other(explain under 7g)
OMonitorind' ORecovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
UAquifer Recharge ❑Ground%vater Remediation 0.5 GALLONS
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop)' ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE HOLEPLUG
❑Geothermal(Heatin-OCooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:-. 05/18/23
ia.Well location:
BUCK STEAM STATION
Facility/Owner Name Facility ID}(ifapplicahle) S.Certification:
1555 DUKEVILLEROAD SALISBURY 28146 05/22/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
ROWAN By signing this form:, 1 hereby certify that the well(s) "'as(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'tvell oiviner.
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 42' 49.26" 800 22' 06.21° W You may use the back of this page to provide additional_well site details or well
N
- abandonment details. You may also attach additional pages,i f necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach hell coastnrction record(s)if available. For multiple it jection or non-water supply
u•e/LsONLY with ibe sane con.ru•uctian'ribandgnutenl,yam r•mt snbniir one jorm. 10a. For All Wells: Submit this form within 30 days of completion of well
6a:Well ID#: TPZ-24 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 13.0 (it) 1617 Mail Service Center,Raleigh,NC 27699-1617
lOb. For Injection Wells: Ili addition to sending the form to.the address in IOa
1.0 above, also submit one copy of this form within 30 days of completion of well
6c.,Borehole diameter-. (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Pro_grarn,
Wat
er ater level.below ground surface: (ft.) 163G Mail Service Center,Raleigh,NC 27699-1636
IOr. For Water Supply& lrijection Wells: In addition to'scnding the form to
6e.Outer casing length(if known): (ft.) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known):
Form G W-30 North Carolina Depai'nnent of Environment and Natural Resources-Division ofWater Quality Revised March 2013