Rowan_Well Abandonment_20240325

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Derry L. Huneycutt 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-tvatei supply wells ONLY with -'the same
construction/abandonnzent,you can submit ore form.
2663-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 6.5 (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Granular
2.Well Construction Permit#:
393412-1
List all applicable well permits tie.County,State,Variance,Injection,etc.)ifknown 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use): ,
Water Supply Well: 7e.Sealing materials used(check all!that apply): • •
❑Agricultural OMunicipal/Public 0 Neat Cement Grout 21 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 21Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation • 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring •. ❑Recovery . -
Injection Well: 7f.,For each material selected above,provide amount of materials used:
❑Aquifer Recharge ' OGrtiundwaterRemediation 850 lbs- Bentonite Chips
❑Aquifer Storage and Recovery ❑Salinity Barrier •
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control I.
. 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer . Well was gravity filled with bentonite chips from
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bottom to ground,surface.
4.Date well(s)abandoned: 6/19/23 • i,
5a.Well location:
South Ridge Properties, LLC
Facility/Owner Name Facility ID#(if applicable) 8.Certification:,
331/357 Peach Orchard Rd., Salisbury 28147 L. fl • 7/1/23
Physical Address,City,and Zip Signature of Celified Well Contractor oarell Owner Date
Rowan 407B 036
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
(if well field,one lationg is sufficient) 9.Site diagram or additional well details:
You'may use the back of this page,to provide additional well site details or well
N W • abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED ,SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells 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
6a Well ID#: abandonment to the following:
j, ' \ Ir• '-' Division of Water Resources,Information Processing Unit,
�+ 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 190 (ft) MAR 2
2024 10b.For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2 (in.) ltl t;rif .:;;n ri ar__�Q donment to the following:
E'pat BOG
150 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (R-) 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 abandoned.
6f.Inner casing/tubing length(if known): (ft) .
6g.Screen length(if known): (ft) -
Form GW-30 North Carolina Department of Environment and Natural Resources—'Division of Water Resources Revised August 2013

•
# 9—Well Diagram 2" Well Diameter ,
( •No Casing
•
Removed
Casing Depth.
•
•
•
Unknown
0' to 190' Filled with
Bentonite Chips
190'—Total Weli Depth