Davidson_Well Abandonment_20240903

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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 1 G W-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned-
7b.Approximate volume of water remaining in wells Unknown al
NC Well Contractor Certification Number PP g O'_(gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used:_ yp
2.Well Construction Permit#: W-24-47
List all applicable well eonvtnecnon permtis(i.e.1/1C,Couniy,Stale,6•'ariunce.etc.)if knoun 1 0 oz.
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 * ' ❑f3entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cemdnt Grout Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) e Concrete GroutC)E P ;� (024 ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonit 1 "?a�: " '.b other(explain under 7 )
❑Monitoring ❑Recovery `-
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete mix 5 cubic yards
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Poured concrete directly into well casing and
filled to within 3 feet of surface with a 12"
4.Date well(s)abandoned: 8/22/24 thick concrete plug installed on top.
5a.Well location:
Donnie and Renee Apple N/A
Facility/Owner Name Facility 1D4(if applicable) 8•Certification:
1670 Old US Highway 29 //e izaz?S-1-A 8/22/24
Physical Address,City,and Zip Signature of Certified Well C ntmctor ar Well Owner Date
Thomasville, NC 27360 01-007-C-000-0008
By signing this Dorm, 1 hereby cent that the well(s) was (were) abandoned in
County V i Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and That a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient) 9.Site diagram or additional well details:
35.855789 N 80.169206 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
Attach well construction records/if available. 1•br multiple injection or non-waler sppply well.,
ONLY with the same c•onvinvction ahondonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 43 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1Ob.For Iniection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter: 20 (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- Unknown (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown I Oc.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016