Union_Well Abandonment_20240507 (2)

WELL ABANDONMENT RECORD JFar Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. HUneyCUtt 7a.Number ofwdh being abandoned:
Well Contractor Name(or well owner personally abandoning well on hisJher property) For multiple injection or non-water I supply ivells-'ONLY• with the same
conrtruclion/abandanme»!,you can submit ane yarn.
2465 A II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 150 (gal)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Granular
2.Well Construction Permit 4: 23-252
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)ifinmvn 7d.Amount of disinfectant used 1/2 Ib.
3.Well use(check well use):
Water Supply Well: 7e:Sealing materials used(check all that apply):.
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑•Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: m Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Infection Well: 711 For each material selected above,provide amount of materials used;
❑Aquifer Recharge ❑GroundwaterRemediation 250 IbS-Bentonite Slurry
❑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 Well was pumped with bentonite slurry through.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
a 1"trernie pipe extending down into,well,from,pottom
I, ;-t� .,t
4.Date well 10/24/23 s)abandoned: to the top..I
Sa.Well location: MAY
Stacy Faile/SM Smith&Sons Inc. uFA
Facility/Owner Name Facility ID#(if applicable) 8.CerliRcation:'
4009 Poplin Rd, Monroe 28110 (well#2) 11/10/23
Physical Address,City,and Zip Si ofCertfficd Well Contractor c6,Wcll Owner Date
Union 08300040E By signing this;/orm,I hereby terrify that the ivell(s)was Overe)abandoned in
County Parcel Identification No.(PIN) accordance with,I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that'a copy of this record has been provided io the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
ivells ONLY with the same constructionlabandonment,you can submit one form 10a.'For All Wells: Submit this form within 30 days of completion of Well
6a.Well 1D11 abandonment to the following:
Division of Water Resources,Information Processing Unit,
120 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
i
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c Borehole diameter. 6 (�) above;also submit one copy of this,form within 30 days of completion of well
abandonment to the following: 1�
20 Division of Water Resources,Un,'derground Injection Control Program,
6d.Water level below ground surface: (fL) 1636 Mail Service CeInter,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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
i
6g.Screen length(if known): (ft.) -
Form GW-30 North Catlin Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

# 9—Well Diagram 6 Well Diameter
No PVC Casing
Removed
Casing Depth
Unknown
0' to 120' Pumped
with'Bentoriite
:.
120' —Total Well Depth

11
WELL ABANDONMENT RECORD For Internal'se ONLY:
This form can be used for single or multiple wells
- i
1.Well Contractor Information: 'WELL'ABANDONMENT DETAILS
John W. HuneyCutt 7a.Number of wells being abandoned
Well Contractor Name(or well'owner personally abandoning well on his/her property) For multiple injection or non-iv'ateri supply wells ONLY with the same
cmrstruction/abandonment,you can submit one form.
2465-A ( ' 97.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Granular
2.Well Construction Permit#: 23-308 .
List all applicable well permits(i.e.County,State,Variance,Injection,eta)if known 7d Amount of disinfectant used 112 lb:
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) OResidential Water Supply(single) , ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared). ❑Concrete Grout ❑Drill Cuttings
[]Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: IZI Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery i
Injection Well: 7E For each material selected above,provide amount of materials used;
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs- Bentonite Slurry
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
DExperimental Technology ❑Subsidence Control 7g•.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well.was pumped with bentonite slurry,through
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a 1"tremie pipe extending down into:well from bottom
4.Date well(s)abandoned: 10/24/23 to the top.
Sa.Well location: iMAY 1 /Q14
Stacy Faile/SM Smith&Sons Inc.
Facility/Owner Name FacilityM#(if applicable) 8 itifieati0n: �UF'X
4009 Poplin Rd, Monroe 28110 ( - t'�g` 11710/23
Physical Address,City,and Zip 'Signature of Certified Well Con actor or Well Owner Date
Union 08300040B By signing this form,I hereby certify that the ivell(s)ivas(tvere)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:
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/abandonmen4 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: 85 00 1617 Mail Service Center,Raleigh,NC 27699-1617
r
10b.For Iniection Wells: In addition to sending the form to the address in 10a
tic Borehole diameter 6 (�,) above,also submit one copy of this:form within 30 days of completion of well
abandonment to'the following:
i
20 Division of Water Resources,Underground Injection Control Program,
6d Water level below ground surface: 00 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) the address(es)'above, also submit I one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known): (ft)
I
6g.Screen length(if known): (ff)
I
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I •

# 9—Well Diagram 6': Well Diameter
No-Steel Casing
Removed
Casing Depth
Unknown
0' to 85 Pumped
with Ben_tonite' .
85'—Total Well Depth