Iredell_Well Abandonment_20230825 (7)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: IVELL ABANDONMENT DTTAILSo
Adam Wilcox 7a.For Geoprobe/DPI'or Closed-Lop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on llisnicr property) well construction/depth,only I GW-30 is needed. lndicatc TOTAL NUMBER of
4396-C wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water reJutining ill ivell(s): (gal.)
Yadkin FOR WATER SUPPLY WELLS ONLY:
Company Nome
7c.Type of disinfectant used:
2.Well Construction Permit N:
List all applicable well consbwctionpern its(i.e.UIC,Conn%State,hartance,etc.)ifkuorn �
7d.Amount of disinfectant used:.
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural LiMunieipal/Public ❑Neat'Cemenl Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) 9 Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑Specialty Grout ❑ Gravel
Aron-Water Supply Sire]]: B Bentonite Slurry ❑Other(explain under 7g)
A Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage !
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the itbandonnlcut procedure:
❑Geothermal(Closed Loop) ❑Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(explai l elm )-, r,
°\ onite and concrete grout slurry. A tremie pipe
4.Date wCll(S)abandoned. 4/24/2023 AUG 2 5'2023vas utilized to assure proper application of
5a.Well location: }kl lurr .
Cain, Anne E NA "°`w- `�fA�' Y
Facility/Owner Name Facility iDN(if applicable) 8.Certifncation:
5066 Harmony Highway, Hamptonviile, NC 27020 A/---
Physical Address,City,and Zip Signature of Certified Well Contractor or Welt Owirer Date
Irendell 4884111953 p,signing this form, i hereby cerli ��1hal the well(s) was(were)abandoned in
) g s f s f�,
County Parcel Identification No.(PIN) accordance with 15A rVCAC 02C,0100 or 2C.0200 Ilrell Conslruclion Slandards
and that a copy of this record has beers provided to the well owner.
5b.Latitude and longitude in degrees/ntinutes/seconds or decinnal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or Additional well detstils:
36.050572 N -80.755154 `,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
SUBDIITTALINSTRUCTIONS
Atrachsrellcrnrsn•eicliw airecd(s)ifm'attable. Pornnrhipleirjecrionornar-trarerstrppiyiveiis 1
0ATY a-10 the same eoasrruetiairabarulmnuerit,you can submit one faux.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well,IDN:AS-8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 60 (ft.) 1617 Mill Set-vice Ccuter,,Raleigh,NC 27699-1617
lbb. For Infection Wells: In additiori'to sending the form to the address in 10a
6c.Borehole diameter. 8.25 (in.) above,also submit one copy of this fonn within 30 days of completion of well
abandonment to the following: 1:
6d.Water level below ground surface: U n known (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,:Raleigh,NC 27699-1636
I
6e.Outer casing length(if known):
NA 10c.For Water Sunnly Sr Iuiectiom Wells: In addition to sending the fonn to the
(ft.)
address(es)above,also submit one copy of this fonn�t7thin 30 days of completion
of well abandonment to the county f health department of the county where
6f.Inner casing/tubing length(if lulown): U n known(f.) abandoned. I'IIP ,,
6g.Screen length(if latown): Unknown' (ft.) F
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
I '