Randolph_Well Abandonment_20220815

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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 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):__(gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELL'S ONLY:
Company Name 7c.Type of disinfectant used: HTH Chlorine
2.Well Construction Permit#: 2022-00002123
List all applicable we//construction permits(1. UIC,County,State,variance,etc.)ijknown 1 3 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) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings
❑b-ri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 1.5 yds3
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑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) Poured concrete directly into well and filled to
top of casing terminated above the land surface.
4.Date well(s)abandoned: 8-10-22 ty
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5a.Well location:
Klaussner Furniture Industries N/A AI)� ZQ2�
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: t r€4;ajW 1 Pr:^: 'rq Ur%A
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1800 US Highway 64 E. Asheboro, NC 27203
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Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph 7761912926
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 been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35 deg. 42.325' N 79 deg. 46.743' 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 records)(available.For multiple injection or non-water supply wells
ONLY with the same construction/abandonmem,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: 150 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6 above,also submit one copy of this forth within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Unknown Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ftt) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) loc.For Water Supply&Iniecti I n Wells: In addition to sending the form to the
address(es)above,also submit oneicopy of this form within 30 days of completion
of well abandonment to the county, health department of the county where
6E Inner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(ifknown): Unknown (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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