Iredell_Well Abandonment_20230825 (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILSI
Adam Wilcox
7n,For Geoprobe/DPT or Closed-Loop Gcolliermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on hiSALer property) well constniction/depth,only 1 GW-30 is needed, Indicate TOTAL NUMBER of
4396-C wells abandoned:
NC Well ConlractorCertification Nuinber 7b.Approximate volume of water ren nining in well(s): (gal.)
Yadkin FOR WATER SUPPLY W1;LLS ONLY:
Company Name
7c.Type of disinfectant used:
{
2.Well Construction Permit 9: I
Last all applicable bell construction pernills(i.e.VIC,Countyy,Stare,I'artance,etc.)lfknaurr
7d.Amount of disinfectant used:
3.Well use(clieck well use):
Water Supply WOM 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Pubtic ❑Neat Cement Grout j ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout O Dry Clay
❑Industrial/Commercial []Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑ Gravel
Mon-Water Supply Well: a Bentonite Slurry ❑ Other(explain under 7g)
a Monitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
0Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test OStonmvater Drainage
❑Experimental'Technology ❑Subsidence Control I'
7g.Provide a brief description of the Abandonment procedure:
❑Geothermal(Closed Loop) ❑'Tracer The well was filled to. the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(expWn,utldgQg r,
s)abandoned: 4/24/2023
a.Hate well(s) "1 ntonite and concrete grout slurry. A tremie pipe
AUG 2 5'2023 Was utilized to assure proper application of
Sa.Well location: slurry.
Cain, Anne E NPOOw-9410 ,�fysso* rY
Facility/OwnerNamc Facility IDA(ifopplicable) 8.Certification:
5066 Harmony Highway, Hamptonville, NC 27020 ._ 0�1r-Ole o,1�
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Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953 By s! nht this or•nt, I hemb y ceni that the wells it-as were abandoned in
) s g f � f , 11 l l
County Parcel Identification No.(PIN) accordance frith 15A tYCAC 02C.0100�or 2C.0200 O'ell Construction Standards
and that a cop),of this record has been Provided to the well owner.
Sb.Enfilade and longitude in degreeshninutcs/seconds or decimal degrees;
(ifwell field,one lnt/long is sufficient) 9.Site diagram Ot'additional ri'CII details:
36.050572 ,�, -80.755154 `j, 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 wel/cautructiou records)lfavailable.ra nnrlllple In jectlon a,mn-ararerstrpply are7b �,
UrvI,Y wlrh tke same catcrrncriarr'abordnnunenr,pan carrsubnrlr ore loran' I On. For All Wells: Submit this form within 30 days of completion of%veil
6a,Well 1DM AS^6 abandonment to the follo%%nng: i
1
Divislon ofWi(er Resources,Iitfm•matioti Processing Uni(,
6b.'Fotat well depth: 60 M.) 1617 Mail Service Ccntcr,Raleigh,NC 27699-1617
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10b.For Injection Wells: hi additioti.'to sending the form to the address in 10a
6c,Borehole diameter: 8.25 (ill) above, also submit one copy of this f onn within 30 days of completion of well
abandonment to the following:
Gd.Water Icvel bolo»'ground surface:
Unknown Division of Water Resources,Uuderground Injection Control Program,
(ft.)
1636 Mail Set-vice Cettt r,Raleigh,NC 27699-I636
1
6e.Outer casing lellgih(if known): NA (f() 10c.For Water Sunuly&Inieefimi 11,ells: In addition to sending the form to the
address(es)above,also submit one copy ofthis form within 30 days ofcompletion
of well abandonment to the county cop,
department of the county where
6f.Ituter casing/tttbiiig length(if known): Unknown(ft.) abandoned.
6g.Screen lecigih(iflmown): Unknown
Fonu OW-10 North Carolina Department ofrnvironmenial Quality-Division of Water Resources Revised 2-22-2016
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WELL ABANDONMENT RECORD For Internal Use ONLY: l
1.Well Contractor Information: WELL ABANDOMNIEN'I'DETAILS
Adam Wilcox 7a.For Geoprobe/DPT or Closed-1, 1)Geothernnal Wells having the same
Well ContractorNante(or well owner personally abandoning well on his./her property) well construction/depth,only 1 GW-30lts needed. Indicatc OTAL NUMBER or
4396-C wells abandoned:
i
NC Welt Contractor Certification Number 7b.Approximate volume of water t•etl ta j ping in well(}): (gal.)
Yadkin FOR NVATER SUPPLY NvELLS 01N1,'
Company Name
7e.Type of disinfectant used: i
2.Well Construction Permit/t: !
List all applicable treU catshuctibu permits(i.e.171C,Cowt),,Slate,Ym•iance,ew.)lJkumt-n
7d.Amount of disinfectant use([:
3.Well use(check well use):
Water Supply Well: 7e.Scaling nialerials used(check all that apply):
[]Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Healing(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 111 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: d Bentonite Slurry i ❑ Other(explain under 7g)
}Monitoring ❑Recovery
Injection Well: 7C For each material selected above,'provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Reinediation
[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storer ater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the!abandmnnen(procedure:
❑Geothermal(Closed Loop) ❑Tracer a well was filled to the top with a
❑ ther(exIgt❑Geothermal(Heating/CoolingReturn) u "T)
I Nentonite and concrete grout slurry. A tremie pipe
4.Date ne11(s)abando,tet,: 4/24/2023 AUG 2 5.2023 was utilized to assure proper application of
5a.Well location: I000r.- cn Pftc :Mite slurry.
Cain, Anne E NA Dw000Gs
Facility/Owner Name Facility IDN(ifnpplicable) 8,Certification: / I
5066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953
By signing This form, I hereby certif}That the welits) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 JYCAC 02C.0100 or 2C.0200 Mel/Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Lalitule and longitude In degrees/minntcs/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 9.Site diagram or additional well details:
36.050572 N, —80.755154 `j, 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 SUBD3ITTAL INSTRUCTIONS
Atiaeltirellconslructionrecord(.$)iifarailable. For nwlliple injection or non-water supply i elIs
ONIX irilh dre.rame coitstrttctitntlahmidottttenl,you can submit one fibrin.
10a. For All Wells: Submit this forte within 30 days of completion of Nvell
6a,Well IDII•AS-7 abandonment to the following: I„
I
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 60 (ft) 1617;\•rail Service Center,Raleigh,NC 27699-1617
10h.For Iniectiou Wells,: In addition to sending the form to the address in l0a
6e.Borehole dianieter: 8.25 (in) above,also submit one copy of this form Within 30 days of completion of well
abandonment to the following:
Unknown Division ofNater Resources,Underground Injectiou Control Prograat,
6t1.Water level below ground surface: (fit.) 1636 Mail Service Cent i r,'Raleigh,NC 27699-1636
6e.Outer casing length(if know►,), NA (ft.) IOc.For Water Suonly&Injection Wells: in addition to sending the fonn to the
address(es)above,also submit one copy of this form within 30 days of completion
or well abandonment to the county Ihealth department of the county where
6f.In niter casing/tubing length(if known): U n known(f,.) abandoned.
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6g.Screen length(if larown): U n kn own
Form GW-30 North Carolina Department orEnvironmental Quality-Division of Water Resources Raised 2-22-2016