Iredell_Well Abandonment_20230825 (5)

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WELL ABANDONMENT RECORD For lntemal Use ONLY:
li
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Adam Wilcox k i
7a.For Geoprobe/DP'i•or Closed-Loop Geothermal li'cM having the same
Well Contractor Name(or well osvmerpersonally abandoning well on hisAter property) well construction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
4396-C wells abandoned:
V�CCUVED
NC Well ContmctorCertification Number 7b.Apliroximate volume of water renitaining in well(s): (gal.)
Yadkin AUG 2 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company NameUng
1RtCfPR i �i1 t�f� 1 7c.'I'ype of disinfectant axed:
2.Well Consh•uction Permit M DWQMICG
List all applicable hell conclracllnu perntlts(i.e.UIC,Coanly,State,Parlance,etc.)if knann
7J.Amount of disinfectant used: I'
3.Well use(check well use):
Water Supply Well: 7e,Scaling materials used(cheep all lba(apply):
[]Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-wafer Supply Well: 19 Bentonite Slurry ❑ Other(explain under 7g)
mmonitoring Mecovery
Injection Well: 7f.For each material selected above,,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remedintion
❑Aquifer Storage and Recovery ❑Salunity Barrier
0Aquifer'1•est ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geotlternmal(Closed Loop) []Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) The well was filled fo the top with a
bentonite and concreteigrout slurry. A tremie pipe
a.natewe,l(s)abandoned. 4/24/2023 was utilized to assure proper application of
5a.Well location: the slurry.
Cain, Anne E NA
Facility/Owner Name Facility ID//(if applicable) 8.Certiication:
5066 Harmony Highway, Hamptonville, NC 27020
Physical Address,City,mid Zip Sionahire of Certified Well Contractor or Well Owner Date
Irendell 4884111953 ) signing f } f' ()
B•si nin this form, I hereby ceni •{Thar lire wells was were abandoned in
County Parcel identification No.(PIN) accordance with ISA hVCAC 02C.0/00 or 2C,0200 Well Construction Standardls
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been�ron-ided to the well owner.
,
(if well field,one ladlong is sufficient) 9.Site diagram or additional well details:
36.050572 N -80.755154 ii, You may use the back of this page to provide additional welt site details or well
abandonment details. You may also attach additional pages if necessary,
CONSTRUCTION DETAILS OF WELL(S)TIEING ABANDONED SUMMITTAL INSTRUCTIONS
iI ttac/t rre/1 cvnstrr+eNort recari(.r)!f arallnble.I%nt•ntul!!p/e UJecliat or'nwh-vnler srrpp/y nelly i
ONI1'with the same coasirrrctlnntabandartaetrt,you can submit one form.
10a, For All Wells: Submit this fonn within 30 days of completion of well
6%Well IDfI: SVE-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b,'I•otal well depth: 35 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
IOb.For Iniectlou Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter: 8.25 (ln) above,also submit one copy of this fol`rnh within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centel•,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Sunoly&Ijection WI Ifs: In addition to sending the form to the
address(es)above,also submit one copy;of this forth within 30 days of completion
of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if lruowu): Unknown(ft-) abandoned.
6g,Screen length(if known): Unknown (ft.)
Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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o„pynght. 2ID13 Nat�o'n�11 �ograp fc SoGfety, cubed
2,000 1,000 0 2,000 4,000
Feet
PROJECT TILE
FIGURE
ROSCOE'S GROCERY
ATLIN 5066 HARMONY HWY SITE VICINITY MAP
CHAMPTONVILLE, NC 1
Engineers and Scientists
INCIDENT NO I JOB N0. DATE SCALE DRAWN BVICHECKED BY
11443 222069 AUG 2023 AS SHOWN KMC/SJO

MW-9 N
® MW-2 �4
MW-4 r
MW-3 SVE-1
AS-1
RW-2 tJ ®®1J RW-I
MW 1 SVE-4
AS-3 ■ • AS-2
�Q� » ' • ASt
SVE-2
MW-- • .AS°5
MW-14 WSW-1
{ � AS-8 • �' :
MW-10 • AS-9 i r.
U It MW'S
MW-12
MW 1-3 }
r
WSW 1A NI 5 ;
MW-17
MW-11
LEGEND
s
Abandoned Monitoring
® Well (Type II) MW-6
O Abandoned Mw-18
• Air Sparge Well
Abandoned MW-1s 1 .
Recovery Well
Abandoned Soil
Vapor Extraction Well
Active Potable
Water Supply Well
® Abandoned Potable
Water Supply Well f ► `
Approximate Location 4NT ,
of Septic Field y0 '
Parcel Boundary of
© •e: -sr, Maxar,Na hsM G rcgr ��s ��� tn��GI� 1;52r Community
NOTES:
1.Well locations were obtained from previous reports prepared by other
consultants and are approximate. 40 20 0 40 80
2.Water supply well GW-1 was installed by Yadkin Well Co Inc on 2023/03/27. Feet
3.All other wells were abandoned by Yadkin Well Co Inc 2023/04/24.
PROJECT TITLE FIGURE
ROSCOE'S GROCERY
ATLIN 5066 HARMONY HWY SITE MAP
CHAMPTONVILLE, NC 2
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BYICHECKED BY
11443 222069 AUG 2023 AS SHOWN KMC/SJO