Randolph_Well Abandonment_20231204

WELL ABANDONMENT RECORD For Internal Use ONLY:
I'
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Marc Howie 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 I GW-30 is heeded. Indicate TOTAL NUMBER of
3554-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
McCall Brothers Inc FOR WATER SUPPLY WELLS ONLY:
Company Name ��� 7c.Type of disinfectant used: 73% Calcium Hypochlorite
L+"
2.Well Construction Permit#:vS�.✓ s 3 '7�7.
List all applicable well cant action permits(i.e.UIC,County,State,►variance,etc.)ifknown
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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IeConcrete Grout P -❑grill Cuttings
❑Irrigation ❑ Specialty Grout �.-" ..,i. ❑Grayel,,;
Non-Water Supply Well: ❑Bentonite Slurry n qq { er(explain under 7g)
❑Monitoring ❑Recovery J�r V LUff
Injection Well: 7f.For each material selected above,provide amount of materials used:
1n o�mEZavn �!'.:'+ •• 'T e fah' "
Y2❑Aquifer Recharge ❑Groundwater Remediation N 2-a Di e i~r`;:iG
❑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 ff
❑Geothermal(Heating/C6oling Return) ❑Other(explain under 7g)
11/21/23
4.Date well(s)abandoned.
5a.Well location: _t
Cone Hospital-Robins Morton
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1271 Spero Rd., Asheboro, NC, 27205 tom' 11/21/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolf 7752481417 By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Conduction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
.7�ClC7 Ia ti o N -7� ^D r! W You may use the back of this page to provide additional well site details or well
l• abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach vvell consu•nction records)ifavailable.Farnmltiple ii#ection ornon-watersupply wells -
ONLY with the sane consimctionlabandonmen,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 9,-7 (ft.) 1617 Mail Service Center,Raleigh,NC 276994617
��y 10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter its: (in.) above, also submit one copy of thii form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: /v (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
,yam i
6e.Outer casing length(if known): (ft.) l0c.'For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
��jj��jj,,,�� of well abandonment to the cou I ty, health department of the county where
6f.Inner casing/tubing length(if known): / (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I

i
WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
l
Marc Howie 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 I GW-30 is needed. Indicate TOTAL NUMBER of
3554-A wells abandoned:
j-
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): A 0 b oV (gal,)
I
McCall Brothers Inc FOR WATER SUPPLY WELLS ONLY:
Company Name 73% Calcium Hypochlorite
7c.Type of disinfectant used:
v 3
2.Well Construction Permit#:.2 Nuv 31 v t. (� ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflaiown
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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) t(Concrete Grout CA S ^J ;Q Drill Cuttings
❑Irri ation ❑ Specialty Grout " t` �` ❑-Giavel
Non-Water Supply Well: ❑Bentonite Slurry J r(, ,• i�O El�J Other(explain under 7g)
❑Monitoring ❑Recovery J
Injection Well: 7L For each matgr�aliselected above,.provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Gte✓.:.,i'''` (;Inj
L .7 T.
[]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 f�
❑Geothermal Heating/Cooling Return) ❑Other(explain under 7g) <` 't 3 Oq is e, 1�`�'� �v�'CA P� t SLr-A
4.Date well(s)abandoned: �12 I , A 1 jw (1Vvy✓31C
5a.Well location:
Cone Hospital-Robins Morton S°� 'i�'" ���
Facility/Owner Name Facility ID#(if applicable) S.Certification:
1271 Spero Rd., Asheboro, NC, 27205 , 11/21/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolf 7752481417 By signing dhis fortin, 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 Constniction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
N �,g y� 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
SUBMITTAL INSTRUCTIONS
Mach well construction record(s)ifavailable.Foi"nndtiple byection m-noti-watersupply wells
ONLY with the same construction/abandonment,3.011 can submit one fortis.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
'} Division of Water Resources,Information Processing Unit,
6b.Total well depth: / (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in I0a
6e.Borehole diameter: (in.)
above, also submit one copy of this f6rm within 30 days of completion of well
abandonment to We following: ;
6d.Water level below ground surface: ' ' (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
Fes, of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): ;V-Y^ (ft.) abandoned.
6g.Screen length(if known): �Y .Y� (ft.)
U
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILSI !
Marc Howie 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
3554-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 8 (gal.)
�+
McCall Brothers Inc FOR WATER SUPPLY WELLS ONLY:
11
Company Name 73% Calcium Hypochlorite
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC County.State,Variance,etc)iflatotwt , a Z"`
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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single), ❑Sand Cement Grout" k a F-•d %�,D�;Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Concrete Grout ❑"Drill=Cuttings
r
❑Irrigation ❑ Specialty Grout L r .' 2pyravel
Non-Water Supply Well: ❑Bentonite Slurry, r ❑Other(explain under 7g)
❑Monitoring ❑Recovery ,D"" ` '' „ •i
Injection Well: 7f.For each material selectedi'abiive,Fpk0vide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation /j e; "N C j
❑Aquifer Storage and Recovery ❑Salinity Barrier // I'
❑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) 1.S L��r C7^L �{V.11 "' e-')y-1 rc
11/21/23 A� J F' ; rl v ``��C�n (�CINK a,It 4-•
4.Date well(s)abandoned:
5a.Well location:
Cone Hospital-Robins Morton
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1271 Spero Rd., Asheboro, NC, 27205 11/21/23
Physical Address,City,and Zip gignature of Certified Well Contractor or Well Owner Date
Randolf 7752481417 i
By signing this form, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 at•2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
t'f p 1j 'T N'; _7q W You may use the back of this page to provide additional well site details or well
Y -A J / abandonment details. You may also i ttach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable.For•nuetltipleitjectionor»nn-watersupplytvells
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
abandonment to the following:
6a.Well ID#:
/ Division of Water Resources,Information Processing Unit,
6b.Total well depth: ! (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following.
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 10c.For Water Suualy&Iniectio I Wells: In addition to sending the form to the
// address(es)above,also submit one copy of this form within 30 days of completion
f of well abandonment to the county;, health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
I
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource i Revised 2-22-2016

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