Hoke_Well Abandonment_20240301

WELL ABANDONMENT RECORD Forintemal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jason W. Pendley 7a.For Geoprobe/DPT or Closeld-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 j30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
4360A
NC Well Contractor Certification Number 7b.Approximate volume of water(remaining in well(s): (gal.)
American Environmental Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name lc.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(te.UIC,Comity,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: 7.76
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
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❑Agricultural ❑MunicipaVPublic s Neat Ceme k rog s or Pellets
X� _ ti, , Bentonite Chips
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑Sand CementlifLo lka L'1' V Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete GroutMAR 0 1 INN [3D"Cuttings
❑Irri ation ❑Specialty Grout j; L ❑Gravel
Non-Water Supply Well: - - - ❑Bernonitl3l;l'tiir3� F�y-1:7,6 aLng LJpA Other(explain under 7g) -
❑Monitoring ❑Recovery MQ1300
Injection Well: 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 2500 lbs. Neat Cement 50 lbs.
❑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) ❑Tractx
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Remove drop pipe. Chlorinated well waited 24 hrs.
Add bentonite chips, chip out concrete pad, Bore hole
4.Date well(s)abandoned: Feb. 05, 2024 was open without grouf. Filled bore hole with bentonite
5a.Well location: chips capped from T to ground level with concrete.
Hoke County
Facility/Owner Name Facility II)#(if applicable) 8�erfiflcation:
132.Tuxford Court Raeford, NC 28376 9 A 2-5-24
Physical Address,City,and Zip •gnature of Certified Well Contractor or Whd Owner Date
Hoke 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
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:
35.01664 N 79.082992 W You may use the back of this page to provide additional well site details or well
abandonment detail s_You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Pormultiple injection ornon-watersupplywells
ONLY with the same constructionlabandonment,you can submit oneform.
102. For All Wells: Submit this form within 30 days of completion of well
69.Well ID#• abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10h.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 12 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following.
6d.Water level below ground surface: 3 (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): (ft) 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): (ft) abandoned
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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