Cabarrus_Well Abandonment_20230818 (5)

WELL ABANDONMENT RECORD , For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.1)ETAILS
Bill Jr
Y Joe-Payne 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well.owner personally abandoning well on his/her property) well construction/depth,only I G_W-30 its needed. Indicate TOTAL NUMBER of
3542—B wells abandoned:
NC WeII'Contractor Certification Number 7b:Approximate volume of water remaining in well(s): 3'
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
'Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e. UIC,County,State,Variance,.etc.)'ifknown 4.5-OZ
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural. OMunicipal/Public C Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply). ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry.Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation R Specialty Grout ❑ Gravel. .:
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation _Neat Cement- L.J—lb. Bentonite 60—lb
❑Aquifer Storage and Recovery ❑.Salinity Barrier .
❑Aquifer Test ❑StormwaterDrainage FlOWBble F1ll-60-1b
❑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) . ❑Other(explain under 7g)
filled casing with Bentonite pellets and poured flowable fill cement
4.Date well(s)abandoned. 7-25-2023 until approx.2-fbgl and poured neat cement inside casing to near the
5a.Well location: - a TOC and placed the lid on the manhole for the vertical well.
(Former) Servco 00311 00-0-0000007582
Facility/Owner Name Facility lD#(if a licable) S.Certifi ion: ti.
24 Church Street NE C� aS� �,e AUG 1 8 20238-10=2023..
Physical Address,City,and Zip Sig ture of Certific e l Con ctoj,f,rdrellQ1,,V ff n,}
GABARRUS. 28025 56209806290000 ay Signing this form, I hereby eerti thaYtlt� R1 tvas(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 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 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 well constniction record(s)ifavailable.,For multiple injection or non-'water wells
ONLY with the same construction/abandonment,you can submit one form. . : : : .
`,,A' 10a.'For All Wells: Submit this form within 30 days of completion of well -
6a.Well ID#• V V V—2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
"'6 1 1617 Mail Service Center,Raleigh,.NC 27699-1617
(ft.)
10b:For Iniection Wells: In:addition to sending the for i 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:
6d.Water level below ground surface: �42 :(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (ft.) 10c.For Water Suooly&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
e of well abandonment to the county''health department of the county where
6f.Inner casing/tubing length(if known): u n k (ft.) abandoned.
6g.Screen length(if known): 5 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016