Montgomery_Well Abandonment_20240710

WELL ABANDONMENT RECORD For l lnenla l l l se ON LY:
1.Well Contractor Information: WELL ABANDON�II:N'I'UE'1'Al1.S
Arthur Oakes Rossomando 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or%veil owner personally abandoning well on his her properly) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of"
wells abandoned.t
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 240 gal.)
FOR WATER SUPPLY WELLS ONLY:
Company Name Bleach
7c.Type of disinfectant used:
2.Well Conslrnction Permit tt: (/�i/��
Lirr all applicable well conarnicnun/enwty(i.e.WC.Coun(l..State.tiwiatwe,etc.)rJknmen 1.0 gal
7d.Amount of disinfectant used:
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) NResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) e Concrete Grout ❑ Drill Cuttings
Dirrigation ❑Specialty Grout ,Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Gravel 33 eu ft
CAquifer Storage and Recovery ❑Salinity Barrier
Concrete 6 CLI fit
❑Aquifer Test ❑Stonm%vater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed pump and discharge line Dug down roughly 7a below grade.Cut lop of steel easing off
❑Geothermal(Heating/Cool i ng Return) ❑Other(explain under 7g)
Reinserted approx 50 a of discharge line to route displaced water away from immediale work area.
4.Date well S abandoned: 6/1/2024
O Shoveled in approx.33 cu a of g(avel.Topped oft with approx.6 ni ft of concrete(dry premix).
S a.Well location: Added app..2 w a d W naele b bra a plug aer lop d rnsmg Badfie we+argmal spoie.seed and hay tie area
A.O.Rossomando
Facilityr'Owner Name f aaht :1)-t o,ggdicable) 8.Certification:
271 Hogan Farm Rd, Ether NC 27247 .4.0. / _
Physical Address,City,and Zip Signature of Certified Well Cnntmoor or Well O) n E%._* • le
Montgomery 766100764342
By signing this Joint, f hereby certify that the Il{eµsl t`a3/fir' ITndonerl in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C. Ve C is .Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds of-decimal degrees: (rll;*15iit`�i� �•�^alai:' UrA
(ifwell field,one Int/long is sufficient) 9.Site diagram or additional well details: Dah'Gt3Cv
35.441450 79.781462 ��, 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".
CONSI'RL(`PION DI I': llS OP N EVIJS)BEING ABANDONED SUBM TI'AL INSTRUCTIONS
Auach„ellcm"trucit irecord(s)farunlable ("ireundriplrnn/ecrinnoi•oat-wnrer.enrytpl}Ncllt
ONt.l'a ah the same consituctiott ahamkinment,you can subunit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well I Dui: abandonment to the following
Division of IYater Resources,Information Processing Unit,
6b.Total well depth: 287 (fit.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniectimt%ells: In addition to sending the form to the address in 10a
6c.Borehole dinfneter: 6 (1n) 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: 33 (ft) Division of Water Resources,Underground Injection Control Program,
1636 6lail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) I0c.For Water Seamy&Infection 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 %veil abandonment to the county health department of the county where
6f.Inner casing/tubing length(if know it):_(ft.) abandoned.
6g.Screen length(if known): (ft.) (0
Fnrnt UN'-30 Nunh Carolina IDep;uvnem o(lasvironmenud Quality-Division of Water Resource. Rrs iced 2-22-20 I G

mont8om�?'rg county fil�?alth
environmental %,blth 5 action
217,5� Main SI.
Troy, NC 27371
phonv_ #: (910)572-85175
fax #: [phone]
Well Abandonment Permit
Permit Number 2024011A Associated Permits
Owner Name Arthur Oakes Rossomando Parcel ID 7661-00-76-4342
Address 271 Hogan Farm Road Phone# [phone]
Ether, NC 27247
Well Type Drilled
911 Addes rs 271 Hogan Farm Road
Subdivision Map/Phase Section] -Lot#J
'This permit is subject to all information provided on the well permit application. The well must be constructed in accordance with all
state and local regulations. A copy of this permit must be on site during abandonment of this well. A copy of the well abandonment report
shall be submitted to the Montgomery County Environmental Health Department within 30 days after abandoninq well.
Site Sketch
Comments: Well to be abandoned in accordance with NC Well Construction/Abandonment standards. Contact MCEH
with questions.
Issued By Date
(permit expires 30 days from this date)
Abandonment Completed By I-Aur c%ke,5 g0#4,fvW0 GW-30 Receive
Abandonment Approved_By Date Completed,. /�/��`T