Hoke_Well Abandonment_20241001

WELL ABANDONMENT RECORD I
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:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (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 t#:
List all applicable well conslrnc•lion permits(t.e.UIC,County,,Stale,Variance•etc.)ifknoum • 7 oz.
7d.Amount of disinfectant used.
3.Well use(check well use):
Water Supply Well: 7e.Sealing matt igls used(check pl;tll9tap
OAgricultural ❑Munici I/Public ❑ Neat Cement Grout tonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Gro� •' ry ❑D Clay IJ r
❑Industrial/Commercial ❑Residential Water Supply(shared) ®Concrete Grout J , 2024 ❑ Drill Cuttings
❑Irri ation ❑ Specialty Ortiry[:`F.;6,i" � •• �;.- 'a],.�avel
Non-Water Supply Well: ❑ Bentonite Slurry EMNCc' (explain g)
G' ❑Other ex lain under 7
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 1.5 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control -g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7g) Poured concrete directly into well casing
and filled to within 3 feet of land surface and
4.Date well(s)abandoned: 9/24/24 installed 18-inch thick concrete cap on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility lD#(ifapplicable) 8.Certification:
777 Wayside Road G� '1�1'y,1 #2 '57-4124/24
Physical Address,City,and Zip gignature of Certified Well Contractor or Well Owner Date
Raeford, NC 28376 494660201001
f By signing this form, !hereby cerl�that the well(s) was (were)abandoned in
County f7//e _ Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
wee 56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: caul that a copy of this record has been provided to the well owner.
(ifwell field,one latilong is sufficient) 9.Site diagram or additional well details:
35.038876 N 79.103854 `l You may use the back of this page to provide additional well site detai Is or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF W ELUS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Allachseellcomirzictionrecord(s)ifavailable.Formallipleinjectionarnon-u,alersupplyu,ells
ONLY with the some constriction abandonment,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: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 276"-1617
lob.For Infection 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.«ater level below ground surface: Unknown —(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Suooly&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): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016