Rutherford_Well Abandonment_20220722

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 personallyabandon Lon bi rj a well construction/de th,only1 GW-30 is needed. Indicate TOTAL NUMBER of
N C W-2150-A ��f\7�D wells abandoned: p
NC Well Contractor Certification Number J U L 2 2l'22 7b.Approximate volume of water remaining in well(s): 210 (gal.)
Justice Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name A"firafteeft 4Rk
t�i++K�/8�4 7e.Type of disinfectant used: 73 �o powder chlorine
2.Well Construction Permit#: V V,n,�2-0025
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.)ifknown 1 O 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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) X Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout X Gravel
-Non=WaterSupply-Well. — -- X Bentonite Slurry ❑ Other(explain under 7g)
XMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 4 yards pea gravel no fly ash cement
❑Aquifer Storage and Recovery ❑Salinity Barcier
❑Aquifer Test ❑Stormwater Drainage 1 yard gravel
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Gravel pour eernent pump
4.Date well(s)abandoned. 3/03/22 Well was 140' deep
5a.Well location:
The Broadway Group, LLC
Facility/Owner Name Facility ID#(if applicable) S rtification:
$457 Bostic sunshine Hwy_, Bostic NC 28018 3/03/22
Physical Address,City,and Zip ignature of Certified WeX Co c r or Well Owner Date
Rutherford 16351008 By signing this form, I hereby certy�that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
_35..445.84 N-8.1_.81.369---_ _`1 You may use the back of this Fagg to provide additional well site details or_Svell_
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-watersupply 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 ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: (.ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6e.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: 40 0 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 80 (ft.) 10c.For Water Sunoly&Infection 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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016