Iredell_Well Abandonment_20240731 (4)

WELL ABANDONMENT RECORD For Internal Usc ON IN:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy.Joe Payne .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
4532-B wells abandonea.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining is well(s)- —8 (gaL)
Excel-SRP Environmental "i V E J FOR WATER SUPPLY WELLS ONLY:
�:- h"'Z 4.
Company Name Chlorination-CA
I Q � 7e OCL2
( )Type of disinfectant used:
2.Well Construction Permit#: JUL V ' 2024
List till applicable well construction permits(t e.UIC,Corany,Stare.Variancw,etc.)it' 3-02
I—, +�:' 7d.Amount of disinfectant used:
3.Well use(check well use): il'�r' Ary f. .3,o
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public s Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) IN Concrete Grout ❑Drill Cuttings
❑Irrigation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
PlMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite— 25 Ibs concrete — 15 Ibs
El Aquifer Storage and Recovery USalinity Barrier
❑Aquifer Test ❑Stomtwater Drainage neat cement-- 10 Ibs
OExperimental Technology ❑Subsidence Control
❑GecKhertnal(Closed Loop) ❑Ter 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7 ) Dropped Calcium HypOChlorite into well and filled
casing with bentonite pellets and poured neat cement
i.Date well(s)abandoned: 7/2/2024 until approx 2-fbgl and poured concrete inside casing
5a.Weil location: to near TOC and placed—Won the manhole
Gordon Iron &Metal MO-3735
Facility/Owner Name Facility If)#(if applicable) 8.Ce lion:
1300 Salisbury Rd, Statesville, NC 28677 7 2
Physical Address,City,and Tip Si tnae f tficd We Con for or a nee to
Iredell 4744819411.000
By signing tins form,I hereby certify that the wells) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees: and that a copy of this record hay been provided to the well owner.
(if well field,on:lat/Iong is sufficient) 11.Site diagram or additional coca details:
35.773476 N (-)80.858403 W You may use the back of this page to provide additional well site details or well
abandormnent details. Yon may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Aaach well conslnccfion record(t)ifatnilable. For mulliple injection or non-watersupply wells
ONL F with the same concrrucrion/aiwndonment,you can submit nne form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MRW-7 abandonment to the following:
Division of Water Resources,lefornatien Processing Unit,
6b.Total well depth: 40 AL) 1617 Mail Service Center,Rukk*NC 27699-1617
10b.For injection Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (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: —23 0L) Division of Water Resources,Undergrnad Iajeefion Control Program,
16M Masi Service Center,Raleigk NC 2709-16M
6e.Outer casing length(if known): na A) 10c.For Water Supply&Injection 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
6f.inner casing/tubing length(if known): na (ft.) abandoned.
6g.Screen length(if known). 15-40 (�)