Iredell_Well Abandonment_20231006

WELL ABANDONMENT RECORD ForintemalUseONLY:
1.)Yell ContractlIor Information: WELL ABANDONMENT DETAILS
ear 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Wp.il Contractor Name(or well owner personally abandoning well on Ids/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
,r' �� wells abandoned:
:35NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
YADKIN WELL COMPANY�^ING. ry FOR WATER SUPPLY WELLS ON _ C7
Company Name �7 CU 6 �
P y: ct�_e 0G( q- C `�, 7c.Type of disinfectant used:
2.Ne11:CanstructiomPermit#: ����I-��Q y O C TA C. 2023
List'nll applicable well construcdoit permits(i.e.UIC,County.State,Variance,etc.)ifk»own
7d.Amount of disinfectant used:
3.Well use(check weirusc)': ovja \ -
Wdier Supply.Well: 7e.Sealing materials used(check all that apply)':
❑Agricultural t7Municipal/Public D'' Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Veeside'nt 11
ial Water Supply(single) 4and Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Ir,i ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ifBentonite Slurry w j'kS-V„J ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Grotindwater Remediationf),1.i,Aquif -�I�r��/
Aquifer Storage and Recovery- ❑Salinity Barrier ` ,' Q `�_
0Kquifer Test ❑StormwaterDrainage• � � )
JEzperimental Technology []Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑deothe n"lal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Cooling Return) ❑Other(explain under 7g) 3mbG'Z% 4"ti' �i�uJ� V CYyr 3� Ilrj� Ih W e
4.Date-well(s)abandoned: ��^`/ 1 n
s(. ?...::i:;:H:.tat:'i. ,.;.tt;:. Ct.ts4 e d �ct O�ca.11 ii 0LAu, Y- AiA
Sa:•Wcll'locationi' '' ' •' ' -
Facility/Ow-ner ame.' Facility ID9(if applicable) 8.Certific,tion:
Physical Address;City,and.Zip ' ""' Signature of Csitifled Well Contractor or Well Owner Date
_ , #By signing.lft)s jonn, 1 hereby certify that the well(s) was(were) abandoned in
County: Parcel Identification No.(PIN) accordanci. th 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a`,� of this record has been provided to the well owner.
5b.iLatitude and longitude in degrees/minutes/secoAds or decimal degrees: -�
(ifv�cll field,one lat/long is sufficient) 9.Site diagram or additional well details:
����� N a �V You may use the back of this page to provide additional well site details or well
J T abandonment details. You may also-attach additional pages if necessary.,
-CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
rr:^�/tp,ellcoustructionrecord(s)ifavoilable.Fa•btultiplehyectionornon-watersttpplywells SUBMITTAL INSTRUCTIONS
i/NL'Y with the scone constructionlobandottment,you curt submit one form. • -
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#: �}
i Division of Water Resources,Information Processing Unit,
66.Total well depth: 1 (ft.) 1617 Mail Service Center,Raleig N h, C 27699-1617
10b.For Injection Wells:. In addition to,sending the form to the address in 10a '
6c:t3orcliotctdameter "`� (in.) J C �� above,also submit one copy of this form within 30 days of completion of well
S f hi-,abandonment to the following:
6d.!Wa
# ter levebelaw ground su ft.)
' ( � Division of Water Resources,Underground Injection Control Program,
l:; rface: (
1636 Mail Service,Center,Raleigh,NC 27699-1636
- 1(f o�
6e.Outer casinglength(if known): (ft.)
(� 10c.For Water Supply&Iniection Wells: In addition to sending the form to.the
s
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 known): " (ft.) abandoned.
6g.,Screen length(if krioivn): (ft.)
.arm GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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