Alamance_Well Abandonment_20240311 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
III
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed)too op 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:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: I
2.Well Construction Permit#: W 10400614
List all applicable well construction permits(i.e.WC,County,State,Variance,etc)iflrnown
7d.Amount of disinfectant used:P
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public s Neat Cement Grout ❑Bentonite Chips or Pellets
i
❑Geothermal(Iieating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slung ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ®Groundwater Remediation 3-941bs bags
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage I
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Three bags of 941bs neat;c i went 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: y29/2024 !. , �„
5a.Well location: I
Tarheel Army Missle Plant ,....
tnc�.r�l�l`� ;? ,r., 'y 1JO.
Facility/Owner Name Facility 1D#(if applicable) 8.Certification: ( r
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 I 02/28/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or,Well 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 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: ' I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.0987792 N -79AO89426 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-water supply wells
ONLY with the same conrtructionlabandonment,you can submit one form.
10a. For All Wells: Submit this"form within 30 days of completion of well
6a.Well EM: IP-N.09 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 addiii n to sending the form to the address in 10a
4S above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: j
i
6d.Water level below ground surface: 20 (g,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Centier,Raleigh,NC 27699-1636
`
45 10c.For Water Supply&Injection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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
6f.Inner casing/tubing length(if known): NA abandoned. 4
II
I
6g.Screen length(if known): NA
I
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I�