Harnett_Well Abandonment_20240514

WELL ABANDONMENT RECORD l
For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAIL'S
David E. Meyer
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the saute
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
2527-A wells abandoned:
NC Well Contractor Certification Number 71b.Approximate volume of water remaining in well(s): 0 (gal.)
Protocol Sampling Service, IrIC. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: H IT
H
2.Well Construction Permit#: n a
List all applicable well construction permits(i.e.UIC,Counbt State,Parlance,etc.)if/oourn
7d.Amount of disinfectant used:4 oz.
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
• pp y)°
❑Agricultural
❑Municipal/Public ®Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential 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
❑Monitoring ❑Recovery ❑Other(explain under 7g)
Injection Well:
7f.For each material selected above,provide amount o mgtjArlals usgd'
❑Aquifer Recharge ❑GroundwaterRemediation 2000# bentonite chips
❑Aquifer Storage and Recovery ❑Salinity Barrier 24
[]Aquifer Test ❑StormwaterDrainage 30 gals. cement grout;
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) []Tracer 7g•Provide a brief description of the abandonment proced scure:O C T_-
❑Geothemial(Heating/CoolingReturn) Collier(explain under 7g) Well pump and drop' pipe pulled from well
well sounded, found free of obstructions
a.Date well(s)abandoned:April 19, 2024 chlorinated, filled with Bentonite chips
N C Dept of Conservation Well location: top T casing removed,topped with cement grout, backfilled
N na
Facility/Owner Name Facility ID#(if applicable) 8.Cer ification:
476 NC Highway 24 Cameron NC 28326 U' �/��
w 4/20/2024
Physical Address,City,and Zip Signature of Certified Well Con ctor or Well Owner Date
Harnett 9575-06-2831
Coun By signing this forin, I hereby cert� that the well(s)was(were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standai ds
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a cope of this record has been provided to the well owner.
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.27999 N —79.10008 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
A11ach well consmxrotion record(s)ifavailable.Favuedriplc injection ornon-xmrersupply nrlls.
ONLY with the same conslrrctio✓abandannrent,you can snbnr/t one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1 abandonment to the following:
66.Total well depth: 132 Division of Water Resources,Information Processing Unit,
(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i
6c.Borehole diameter: 6•5 10b.For Iniection Wells: In addition to sending the form to the address in 10a
(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: 109 (ft.) Division of Water Resources,Underground Injection Control Program,
.1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 12 (ft,) 10c.For Water Sunaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit onc�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 (ft,) abandoned. I
6g.Screen length(if known): n a (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revi-A 2_77_Mt F