McDowell_Well Abandonment_20241001

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Justice 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
2150-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 300 (gal)
Justice Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name WA24-0255 7c.Type ofdisinfeetaotused: 73% elorine
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown 1/4 GAL
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apple):
❑Agricultural ❑MunicipallPublic ❑Neat Cement Gt*ut 19 13entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout z1,4 Clay
e(ndustrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 1024 ❑Drill Cuttings
❑Irri ation ❑ Specialty Grgr�., ❑Gravel
No*-Water Supply Well: a Bentonite Slurry 'i � s 9,(lther(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected atone,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 2 bags bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier 2.4 ton pea gravel
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) []Tracer Gravel to 652 bags easy seal, Grout and Gravel
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7 )
To the top.
4.Date well(s)abandoned: 09/09/24
5a.Well location:
Crane Resistoflex
Facility/Owner Name Facility ED#(if applicable) 8.Certification:
1 Quality Way Marion N.0 28752 D. 09/09/24
Physical Address,City,and Zip Signature t17Arfified Well ontractor or Well Owner Date
Mcdowell 078102879732
By signing this form, I hereby certify that the well(s) was(were)abandoned to
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.68239 82.06958 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 record(s)ifavailable. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 225 (ft.) 1617 Mail Service Center,Raleigh,NC 276"-1617
10b.For Inieetion Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mad Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 47 (ft.) 10c.For Water Suouly&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): 00 abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016