Cabarrus_Well Abandonment_20230818 (2)

WELL ABANDONMENT RECORD__ For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.DETAILS
Billy Joe Payne Jr 7a.For Gcoprobe/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-
3542—B wells:abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of-water remaining in well(s)d 1. (gal.)
Excel=SRP Environmental ,—, 9'1ao"� FOR WATER SUPPLY WELLS ONLY:
:Company Name "Li -
Chlorination-Ca(OCI)2
7c:Type of disinfectant used:
2.Well Construction Permit#: �� r �„8 702 .
List all applicable ivell construction permits rt.e.UIC,County,State, Variance,.etc.fJ7known _
7dutl .Amount of:disinfectant used: 0Z
.3.Well use(check well use): 1t t�f5Pi1 t`il turf': ":r'i�LR
C�r'3t?t"n
Water Supply Well: 7e._Sealing materials used(check all that apply):
❑Agricultural. ❑Municipal/Public a Neat Cement Grout- a Bentonite Chips or Pellets
❑Geothermal.(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement,Grout. ❑ Dry:Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ... ❑ Drill Cuttings :....
❑Irrigation r ia Specialty Grout ❑ Gravel. .:.
Non-Water Supply Well: ❑ Bentonite Slurry 0Other(explain under 7g)
IMMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used::
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8-lb Bento.nite-17-lb
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage FlOWable Fill=25-fib
❑Experimental Technology :• ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer .. ' .
Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) . .DOther(explain under 7g).
G filled casing with Bentonite pellets and poured flowable fill.cement
4.Date wells abandoned: '7-25-2023
() until approx.2-fbgl and poured neat cement inside casing to near the
sa.well location: TOC and placed the lid on the manhole for the monitoring well.
(Former) Serno. 00311. 00-0-0000007582
Facility/Owner Name Facility ID#applicable) S.Certificati n:
24 Church Street NE Q4 yk�� ; 8-10=2023
Physical Address,City,and Zip Sig turc of Ccrtifi Wcll Contrector or Well Owner Date -
CABARRUS 28025 56209806290000
By signing this fwm, I hereby certify that the well(s) was (were) abandoned in "
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constnretion 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.4121770 N .• N -80.5807370. W" `l 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 ivell construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY ivith 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#: M�V—I I abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
"'20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: hi 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:
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:
1636 Mail Service Center,Raleigh,NC 276991636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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
6C Inner casing/tubing length(if known): u n k (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016