Stanly_Well Abandonment_20230807 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information: WELL ABANDONMENT DETAILS
John W. Huneycutt 7a.Number ofwells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or nun-wafer supply wells ONLY with the same
constructionlahatdoinnew,you cau submit ano.ftrm
2465-A 202.5
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLSONLY:
Company Name 7c.Type of disinfectant used: Granular
2.Well Construction Permit M 382985-2
List all applicable hell permfis(i.e.Comuy,State,Variance,h jectiat etc.)iflntmrn 7d.Amount of disinfectant used: 1/2 lb.
3.Well use(check well use): �
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mmiicipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings b;,,++ 9 + r�.�%
❑irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: m Bentonite Slurry ❑Other
Pp Y rry (explain under
❑Monitoring ❑Recovery e
Injection Well: 7E For each material_selected above,provide amount of materials usedc
❑Aquifer Recharge ❑Groundwater Remediation 350 IbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stornwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well was pumped with bentonite slurry from bottom
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
to top through a 1"tremie pipe extending down
4.Datew•ell(s)abandoned: 5/23/23 into well.
5a.Well location:
Chuck Nance
Facility/Owner Name Facility 1D4(ifapplicable)
8.Certiti 'on:
32126 Chapel Rd, Albemarle 28001 � U) YY 6/9/23
Pbysical Address,City,and Zip Signature of Certified Well Contractor or Wei Owner Date,
Stanly 3682 By signing this form,1 hereby certify that the ivell(s)ivas(tvere)abandoned in
County Parisi Identification No.(PIN) accordance with 15,4 NGIC 02C.0100 or 2C.0200 Well Construction Standards
and that a cap[of this record has been provided to the ive11 owner.
5b.Latitude and longitude in degrees/minutes/secondi or decimal degrees: "
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBIVIPITAL INSTRUCTIONS
Attach well construction records)ifarailuble. F•or nmltiple hyection or non-water supply
,yells ONLY,vith the sane conrtructimn,17handonnien4 you can submit one fibrin 10a. For All Wells: Submit this foul within 30 days of completion of well
6a.Well UN: abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 165 (f.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For injection 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: 30 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water SuPpIv&iniection Wells: in addition to sending 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
Gf,inner casing/tubing length(if known): (fL) where abandoned.
i
6g.Screen length(if known): (ft.) {
Form GW-30 North Carolina Department of Environment and Natural Resources—Divisiba of X'Vatcr Resources Rcidsad August 2013