Union_Well Abandonment_20220801

WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPT or Closed- oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW!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): 400 (gal)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hypochlorite
7c.Type of disinfectant used:
2.Well Construction Permit#: Union Co. permit#22-275
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 10 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 r e r
❑Geothermal(Heating/Cooling Supply) CResidential Water Supply(single) ❑ Sand Cement Grout + Dry Clay j Z K--- -.j
ED
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout 0 Drill Cuttings I Cl n
❑kri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(e zuLW
❑Monitorin ❑Recove ii�� +� f1�Gafit�
QVIUMOG
Injection Well: 7E For each material selected above,provide amount of materials used: ;a
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 6 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Dry Clay (from on-site) 10 cubic yards
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of#e abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Qther(explain under 7g) Filled well void eomplet'ely with dry clay soil
to within 3 feet of land surface where a 3'
4.Date well(s)abandoned: 7/28/22 thick concrete plug was installed on top.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
3106 Parkwood School Road ' v✓�,y„f �l ZQ 5 A 7/28/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Monroe, NC 28112 �� � 04279006D
By signing this form, I hereby certify that the wells) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C!0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has I been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.899644 N 80.625239 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 ifnecessary.
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 consiruction/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: 35 (ft.) 1617 Mail Service,Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 36 (in.) above,also submit one copy of is form within 30 days'of completion of well
abandonment to the following:
27 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service'Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 10c.For Water SuyDIV&Iniection Wells: In addition to sending the form to the
address(es)above,also submit orie copy of this form within 30 days of completion
of well abandonment to the c!unty health department of the county where. .
6E Inner casing/tubing length(if known): N/A (ft,) abandoned.
i I
6g.Screen length(if known): N/A (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016