MO-29283_48450_CA_WSW_20220603_Well Abandonment Record

CABARRUS
HEALTH
MIMM ALLIANCE CABARRUS HEALTH ALLIANCE
300 Mooresville Rd, Kannapolis, NC 28081
Office: 704-920-1207 fax: [phone] WELL PERMIT
Email:[e-mail]
71-0011
WELL PERMIT NUMBER:
WELL OWNER: Creech Properties
EMAIL: [e-mail]
WELL SITE ADDRESS:
CITY: Kannapolis
1-1 NEW WELL
COMMENTS:
2520 Lane Street
REPAIR OF AN EXISTING WELL
COMMENTS:
ZIP: 28081
DATE ISSUED 06 / 03 / 2022
PHONE NUMBER:919 _880 -0917
7 ABANDONMENT OF AN EXISTING WELL
COMMENTS: Must call us when abandonment occurs and fill out GW-30.
See back of permit for approved well location. Call 704-920-1207 if well cannot be located in the proposed area.
Email: [e-mail]
06/03/2022 06/03/2027
Authorized REHS. Date Issued Expiration Date
ALL REQUESTS FOR GROUT INSPECTIONS MUST BE CALLED IN 24 HOURS IN ADVANCE
HOTLINE # - 704-920-1237

WELL ABANDONMENT RECORD
1. Well Contractor Information:
SCOTT WRIGHT
Well Contractor Name (or well owner personally abandoning well on his/her property)
2801-A
NC Well Contractor Certification Number
B.M. WRIGHT WELL & PUMP SERVICE
Company Name
2. Well Construction Permit #: 71 -001 1
List all applicable well construction permits (i.e. U1C, County, State, Variance, etc.) it known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
IgResidential Water Supply (single)
❑Industrial/Commercial
❑Residential Water Supply (shared)
❑Iri ation
Non -Water Supply Well:
❑Monitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
❑Geothermal (Heating/Cooling Return)
❑Other (explain under 7g)
4. Date well(s) abandoned: 6-1 3-2022
5a. Well location:
CREECH PROPERTIES
Facility/Owner Name
2520 LANE ST.
Physical Address, City, and Zip
CABARRUS
County
Facility ID# (if applicable)
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.41.33 N 80.39.24
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:'
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: STA I/L E N
7d. Amount of disinfectant used: 60Z
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout a Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
39 BAGS
7g. Provide a brief description of the abandonment procedure:
PULLED PIPE AND PUMP, TREATED WELL WITH DISINFECTANT THEN HOLE HOLE WITH HOLE PLUG
8. ertification: e
6-13-2022
Si a re of Certified Wefl ContradUk or Well Owner Date
By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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
Attach well construction record(s) rjavailahle. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: 1
6b. Total well depth: 1 03 (ft.)
6c. Borehole diameter. 6 (in.)
6d. Water level below ground surface: 26
6e. Outer casing length (if known): i V 1A
6L Inner casing/tubing length (if known): A 1p
6g. Screen length (if known):
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Suonly & Iniection 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
abandoned.
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Beverly, Trudy
From: Beverly, Trudy
Sent: Tuesday, June 14, 2022 1:58 PM
To: [e-mail]
Subject: RE: [External] Well abandonment record for Creech Properties I LLC Property, Incident #
48450
Received.
Trudy
Trudy Beverly, L.G.
D-�IE Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
IFepnrlren[ol Gma'nn mental4w
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlyAncdenn gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hit2s://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-mans
File Review Procedures:
hops://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
fts://deq.nc.gov/about/divisions/waste-manaizement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.ne.izov/nedeafWaste%2OManasement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df
https:Hfiles.nc.gov/ncdeq/Waste%20Management/D WM/UST/Corrective%2OAction/UST%2Ofilc%20names%20for%2OLaserfiche.docx
From: [e-mail] [mailto:[e-mail]]
Sent: Tuesday, June 14, 2022 1:43 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Well abandonment record for Creech Properties I LLC Property, Incident #48450
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
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Hi Trudy
Attached is a copy of the well abandonment record for the onsite well at the above property. The site should now be
able to be classified as Low Risk. When available, please send me a copy of the conditional NFA letter and I will
complete the public notice. If you need anything else please let me know.
Thanks
Damien Callaghan
Cedar Rock Environmental