Jackson_Well Abandonment_20220607

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
A. Bruce Hedden 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 GWi-30 is needed. Indicate TOTAL NUMBER of
2042-A wells abandoned: f
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Hedden Brothers Well Drilling, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name H T H
2022-22463-9-11888 7c.Type of disinfectant used:
2.Well Construction Permit#: \
List all applicable well construction permits(i.e.UIC,Corm[),State, Variance,etc.)ii known 1 6oz
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 ❑ Ncat Cement Grout ❑ Bentonitc Chips or Pellets
❑Geothermal(Heating/Cooling Supply) NRcsidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ® Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ® Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation #57 stone--5 tons
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑A uiferTest Cement-pumped-3yrds
9 ❑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) chlorinated well-filled,well with #57 stone and
capped with 3 yards of cement. Casing was cut
4.Date well(s)abandoned: May 11, 2022 off 2ft below ground level.
5a.Well location:
Cedar Creek Racquet Club
Facility/Owner Name Facility JD#(ifapplicable) 8.Certification:
42 Racquet Club Drive Cashiers, NC 28717r 5/11/22
Physical Address,City,and Zip Signature of Certified Wdl Contractor or Well Owner Date
J.acksb 7582-16-4143
"' By signing this_jonn, I hereby ce{•tify that the l( �yyw,er Nb idoned in
County Parcel Identification Na.(PIN) accordance with 1 SA NCAC 02C.'0100 or � oysbttandards
and that a copy of this record has been prov a he we l awner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R. �n��
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: JUN O i v
83.076 r, 35.125 W You may use the back of this page to provide additional well js>t .oeg,a&jor well
abandonment details. You may also attach {p ;li�a^g?4 cessary.
1AlC�:',
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach we/lconslrucrianrecord(s)ifavailab/e. Pastor!tipleinjectionornon-watersupplywells
ONLY with the same constriction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
400 Division of Water Resources,Information Processing Unit,
6b.Total well depth: ({t,) 1617 Mail Service Center,Raleigh,NC 27699-1617
6 10b.For inieetion Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: (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 400 ({t) Division of Water Resources,�Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suaaly&inject!on Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
110 of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
rces Revised 2-22-201 G
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resou
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