Iredell_Well Abandonment_20240731 (5)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WEl l 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 abandoned:
NC Well Contractor Certification Number i f -� 7b.Approrimate vultr o[water remaining m well(s): _8 (gal)
Excel-SRP Environmental F, �•'�-• v
FOR WATER SUPPLY WELLS ONLY:
Company Name AL 3 1 7-OZ4 Chlorination-CA OCL
7c 2
(Type of disinfectant used: )
2.Well Construction Permit#: ,
PA
List aft applicable we11 construction permilx(i.e.byf Xa ,? Ofian c_)!-kno wn
. 3-oz� t+' 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 s Neat Cement Grout a Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑ind ustrial/Commercial ❑Residential Water Supply(shared) iN Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
SMomtoring URtcovery
Injection Well: 7f.For each material selected above
,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite—25 Ibs concrete— 15 Ibs
❑Aquifer Storage and Recooery ❑Salinity Barrier
[']Aquifer Test ❑StormwaterDrainage neat cement— 10 Ibs
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description o(the abandonment procedure:
❑Geothermal(Closed Loop) UTracer Dropped Calcium H
❑Geothermai(Heating/CoolingReturn) ❑ether ex Wnunder7 ) PP ypoehlorite into well and filled
casing with bentonite pellets and poured neat cement
4.Date well(s)abandoned: 7/2/2024 until a OX 2- I and
ppr fbg poured concrete inside casing
5a.Well location: to near TOC TTp_1ac_e&iqd on the manhole
Gordon Iron& Metal MO-3735
Facility/Owner Name Facility IDh(ifapplicahle) 8.C n:
1300 Salisbury Rd, Statesville, NC 28677 7 q y
Physical Address,City,and Zip
.ettifiw Wa Co. or ell ate
Iredell 4744819411.000
By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a ropy of this record has been provided to the well owner.
Sb.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one IaUiong is sufficient) 9 Site diagram or addition{well details.
35.773476 N (-)80.858403 W You may use the bard`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
Atiach well construction record(5)ifa.ailable.Formahiple h!jewtion or wn-water srgiply wells
ONLY with the.same construction/ahandonment,you can wbmit one form_
10a. For All Wells: Submit this form within 30 days of completion of well
62.Well ID#' MRW-8 abandonment to the following:
Division or Water Resources,Information Processing Unit,
6b.Total well depth: 40 at) 1617 Mail Service Center,Raleigh,NC 276"-1617
lOb.For lnjection Wells: In addition to sending the form to the address in 10a
6G 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: —22 (tt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276"-1636
6e.Outer casing length(if knowny na (fL 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 00 abandoned.
6g.Screen length(if known): 15-40 (�)