Union_Well Abandonment_20230724 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Howard L Rushing 7a.For Geaprobe/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 j30 is needed. Indicate TOTAL NUMBER of
3342-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Carolina Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name
� y 23-102 7c.Type of disinfectant used: 70O o HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflarotim
7d.Amount of disinfectant used: oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Publie ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothennal(Heating/Cooling Supply) FiResidential 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: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation ( 8 ) 501b bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Chlorinated Well '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 5/02/2023
Completely Filled Borehore With Bentonite
�'t E�E I\/F •
5a.Well location: 4
AMH NC Development L!� ? ��??
Facility/Owner Name Facility ID#(if applicable) 8.Certification: lilEOrbYyull£flln{rroUr,'R
2432 Waxhaw Indian Trail Rd Indian Trail, NC 28079vr) 5/08/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Nfeftbwner Date
Union 07135016 By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.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 lavlong is sufficient) 9.Site diagram or additional well details:
35.30.400 N 80.41 .400 �, 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 well construction record(s)if available.For multiple injection or non-watersupply wells
ONLY with the same construction/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:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (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: 30 (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): unknown (it.) 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
6f.Inner casing/tubing length(if known): u n kn own (ft.) abandoned.
6g.Screen length(if known unknown): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016