Randolph_Well Abandonment_20230724 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J.MICHAEL VENABLE 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I '
NCWC-2079A
76.Approximate volume of water remaining in well(s): 45 (gal.)
NC Well Contractor Certification Number
VENABLE BROTHERS WELL CONST., INC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: CALCIUM HYPOCHLORITE
2.Well Construction Permit#:
List all applicable well construction pertnits Ae. (11C,Courtin,,State,Variance,etc.)iflmown 7d.Amount of disinfectant used: 14 OZ
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check Sill that apply):
❑Agricultural ❑Municipal/Public 0 Beat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Cominercial ❑Residential Water Supply(shared) 9 Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aqui£erRecharge ❑GroundwaterRemediation WELL MIX: 2.5 YARDS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer CHLORINATED; DEWATERED VIA TREMIE PIPE;
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
FILLED WITH WELL MIX TO SURF+GE... �a
t.Y rV��• ,1 .1 A�6 'i
4.Date well(s)abandoned: 6/30/23 k",L-I I�1-• I-- LJ
5a.Well location: JUL L v A 2023
TOYOTA BATTERY MFG. �rC;; ;,�
Facility ID# ifa licable 8.Certification: lrgoraYx D%' L
Facility/Owner Name tY (� PP ) Cl.i`LtJ'3'O'a
BROWNS MEADOW RD., LIBERTY, NC (a 7�� 7/7I23
Physical Address,City,and Zip tore ofCerrified Well Contractor or Well Owner Date
RANDOLPH 8718203615 By signing this forn7, I hereby certify that the ivell(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I SA 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.894129 N -79.630809 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
Attach irell cotatnretion records)ifcnmilable.For multiple infection or non-watersupply wells
ONLY with the scone constrticilonlabandonnnen/,you can suhmir 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: 302 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in) abandonment to the following:
6d.Water level below ground surface: 5 (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 Sunnly&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
6f.Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Enviromncntnl Quality-Division of Water Resources Revised 2-22-2016