Montgomery_Well Abandonment_20231122

WELL ABANDONMENT RECORD For Internal Use ONLY: �
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPT or Closed-I of 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
2957-A wells abandoned: E
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#:
List all applicable well constructionpermits(1.a VIC,County,State,Variance,etc.)ifhnown 13 oz.
_ 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 ❑Neat Cement Grout I ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
FlIndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 3.5 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier I
❑Aquifer Test ❑Stormwater Drainage 1,
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description oflthe abandonment procedure:
Poured concrete directly into well casing
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
and filled to 12 inches above top of casing,,
4.Date wells 11/20/23 abandoned: terminated above:the land surface.
5a.Well location: 2 2 ,
NC DOT NIA 423
rt:r: _
Facility/Owner Name Facility 199(if applicable) S.Certification: _-
4593 NC Highway 24 ,,L`
0, c„�-x Z`�57-/� 11/21/2'1
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Mt.Gilead, NC 27306 6586 00 38 7209
By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
Count�and Parcel Identification No.(PIN) accordance with 15A NCAC 02&.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has;been provided to the well owner.
5b.Litude or decimal degrees:(ifwell field,one lat/long is suffi 9.Site diagram or additional well details:
35.307155 N 80.060175 W You may use the back of this pave to provide additional well site details or well
abandonment details. You may also attach additional pages ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavoilabte.For multiple injection ornon-water supply wells
ONLY with the same construction/abandonment,you can submit one farm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SWA abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 400 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this form within 30 days of completion of well
6c Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): Unknown (m) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
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
6E Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Reso ces Revised 2-22-2016