Davidson_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
David M. LeGrand,Jr. 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 I GW-30 is needed. Indicate TOTAL NUMBER of
4540-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 5.16 (gal.)
Catawba Valley Engineering & Testing FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Bleach (5.25% Chlorine)
2.Well Construction Permit#: W-24-6
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.)ijknown
7d.Amount of disinfectant used: 1.5
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) RResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commereial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings'
Ohri ation N Specialty Grout ❑Gravel AM`� �S
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain underr 79Y e614
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materam l j,>t:,• j
[]Aquifer Recharge ❑Groundwater Remediation 1 cubic yard-for filling well and construction of concrete cap
❑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
Plumbing removed,disinfectant introduced,filled with grout to surface
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 5/22/2024
5a.Well location:
Russell Bendel N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
305 Cleveland Drive, Lexington, NC 27292 5/23/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Davidson 0603200000028A
By signing this form,I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is sufficient) 9.Site diagram or additional well details:
36.678376 N -80.253412 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additions}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
ONLYwith 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#: N/A abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 28 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (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: 20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to 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
6E Inner casing/tubing length(if known): 00 abandoned.
6g.Screen length(if known): 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016