Iredell_Well Abandonment_20230825 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY: I
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1.Well Contractor Imfornration: 1VELL ABANDONMENT DETAIL
Adam Wilcox 7n.For Geoprobe/DPT or Closed-1p Geotlierinal Wells having the snnte
Well Contractor Name(or well owner personally abandoning well on Itisliter property) well construction/depth,only 1 GW-30 is deeded. Indicate TOTAL NUMBER of
4396-C wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of water retLillitg in well(s): (gal.)
Yadkin FOR WATER SUPPLY WELLS ONLY:
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Company Name
7c,Type of disirtfeclanf used: a'
2.Well Construction Permit 4:
P
Lisl all applicable a ell cWisn ucltott pernilts(i.e.U1C,County,State,Variance,etc.)if knou-ir
7d.Amount of disinfectant used:
3.WeIl use(check well use): ;{
Water Supply Well: 7e.Sealing materials tlsed(cheek a)l that apply):
C1Agricultural ❑Municipal/Public ❑ Neat Cement Grout 1' ❑Bentonite Chips or Pellets
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Watcr Supply Well; 8 Bentonite Slurry ❑Other(explain under 7g)
Hlvloniloring ❑Recovery
Dyecliotl Nell: 7f.For each material selected above,iwovide amount of materials used:
❑Aquifer Recharge ❑Ground\ndtcr Reniediation
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[]Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of(lie it
bamtlarment procedure:
❑Geothennal(Closed Loop) ❑'Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
� -pentonite and concrete grout slurry. A tremie pipe
a.Date well(s)abandoned. 4/24/2023 _-'�L-GBVE,,vas utilized to assure proper application of
5a.Well locatimt: AUG 2 5'2023 the slurry. ?`
Cain, Anne E an `-U
Facility/Owner Name Facility IDA -9hj&16o^ 4.Certif catiion: ��//
5066 Harmony Highway, Hamptonviile, NC 27020 A� 7'020,3'
Physical Address,City,and Zip Signature of Certified Well Conimclor or Well O� Date
Irendell 4884111953
By signing this form, I hereby certify i(hat the u•el!(s) was(trere)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 oi•2C.0200 Well Construction Standards
and that a copy of this record has been provided io file well on-ner,
51).Latitude and longitude in degrees/inhudes/seconds or decimal degrees: I.
(if well field,one latflong is sufficient) 9.Site diagram or additional well details:
36.050572 N -80.755154 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 SUBIMITTAL INSTRUCTIONS I
Altacliirellconslitictianrecord(s)ifavailable.For multiplehVectionwvrou-walersupply wells
ONLY with the same ear trnctimr abmutntnuenl,you can submit one farm.
10a. For All Wells: Submit this form %vithin 30 days of completion of well
6a.Well ID#:AS-9 abandonment to the following:
Division of Wafer Rcsonrccs,Information Processing Unit,
6b.'rotal well depth: 60 (ft.) 1617 A4ail Service Center,Raleigh,NC 27699-1617
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10b F. or Injection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: 8.25 (ht.) above,also submit one copy of this fomn within 30 days of completion of well
abandonment to the following:
Unknown Division of Water Resources,Underground Injection Control Program,
6d.lVater level below ground surface: (ft.) 1636 Mill Ser vice Cente,,r,.Raleigh,NC 27699-1636
TNA 10c.For Water Sanely&Injcetion ..'oils: In addition to sending the form to the
6c.Outer casing length{if known): (ft.) 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
6f.Inner casing/tubing length(if Imowu): Unknown(ft) abandoned.
6g.Screen length(if known): U n kn own M)
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Forin GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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