Burke_Well Abandonment_20231113 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Daniel Summers 7a.For Geoprobe/DPT or Closed-,Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: 1
2579-A �
NC Well Contractor Certification Number 7b.Approximate volume of waterh remaining in well(s): '80 (gal.)
Carolina Soil Investigations, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)iflmown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public C 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) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation neat cement 81 Ibs per well
[]Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) tremie grouted with neat cement
4.Date well(s)abandoned: 10-26-23
Sa.Well location:
Holland's Grocery Incident#28063 ! Nov IT?Il��
Facility/Owner Name Facility ID#(if applicable) 8.Cc cation:
7121 US Hwy 64 Morganton, NC 10-26-23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Burke By signing this form,I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of t his record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.60063 N -81.81953 �, 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 well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-8R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 (ft) 1617 Mail Service'Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the foam to the address in 10a
6c.Borehole diameter: 2" wel I (in.) above, also submit one copy of i ltis form within 30 days of completion of well
abandonment to the following: i
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6d.Water level below ground surface: 23 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service tenter,Raleigh,NC 27699-1636
n/a 10c.For Water Sunoly&Iniee on Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) h
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
611 Inner casing/tubing length(if known): (ft,) abandoned
6g.Screen length(if known): n/a
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016