Alamance_Well Abandonment_20240311 (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL;$
Rawlins E Clarke IV 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 130 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water Ir I aining in well(s): (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: W10400614
List all applicable well construction permits(i.e.VIC,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 G 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)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ®Groundwater Remediation 3-94 lbs bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of tliJ abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Three bags of 941bs neat Bement grout mix with water and tremie
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
grouted from bottom of bore hole to the top.
4.Date well(s)abandoned: 2/24/2024 �-.✓L.?
5a.Well location: '
Tarheel Army blissle Plant I; ,v � t �fi• r I,}
Certification: DWr4iB'G
Facility/Owner Name Facility ID#(if applicable) S. �
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 _ 02/28/2024
Physical Address,City,and Zip Signature of Certfified Well Contractor or We11 Owner Date
Alamance
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.01,00 or 2C.0200 Well Construction Standards
and that a copy of this record has been pi rovided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: j
(if well field,one lat/long is sufficient) 9.Site diagram or additional well detlails:
36.0987646 N -794089202 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
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandonment,you can submit oneform.
10a. For All Wells: Submit this fo i within 30 days of completion of well
6a.Well ID#• IP-N.08 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In additi ito sending the form to the address in 10a
6c.Borehole diameter:
4.5 above, also submit one copy of this form within 30 days of completion of well
(in.) abandonment to the following:
i
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6d.Water level below ground surface: 20 (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): 45 (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit one cop of this form within 30 days of completion
of well abandonment to the county ihealth department of the county where
6f.Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): NA
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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