Yadkin_Well Abandonment_20220815

WELT.. ABANDONMENT "CORD For lntemal'UseONLY:
I
1.Well ontractor Informatation: Ily WELL ABANDONMENT DETAILS
�/��✓t ,/��� 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
,n� O / wells abandoned:
NC Well Contractor Certification Number ^��L��" 7b.Approximate volume of water remaining in well(s): (gal.)
YADKIN WELL COMPANY INCR;__ ' ' �.! �'j FOR WATER SUPPLY WELLS ONLY:
Company Name A(J�j 2 — 7c.Type of disinfectant used: 4t1
2..We11 Construction Permit#: - u
nt List oll applicable well consmvcloon penults(i.e.UIC,CoM%fl ra ar)o)rc;. A known
irj9aj�a 7d.Amount of disinfectant used: y Z
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) 121Cgurete Grout ❑Drill Cuttings
❑lrri ation D Specialty Grout �vel
Nbn=Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑A'quifer Recharge ❑Grodndwater Remediation
❑'Aquifer Storage and Recovery OSalinity Barrier
OAquifer Test ❑Stormwater Drainage [�p+.[.ft�'e ���� Q_—
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑G.eothermal(Closed Loop) OTracer p
❑:Geothermal(Heating/CoolingReturn) ❑Other(ex lain under7g) �v1( Y y0►P !.t+ir2ke1 Ctacltdnk 1OV CtCe_,,e
:•, 'moo ��a' t�;� 'c��t -} c..,T dFF Cws��.y
4.Date well(s)abandoned: 7�2 — ZZ. t
Sa.Well location:
SJ C-:Z�a I
Facility/Owner Name Facility IDN(ifapplicable) 8.Certificatiou:
rl Old vet 7 zl Z Z
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Date
yA,A By signiirg this jorin, 1 hereby cei-tify that the ivell(s) was(itrere)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 01C.0100 or 1C.0100 Well Construction Standards
and that copy of this record has been provided to the well owner.
5b.;Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
3C' 12 12J Q N 8b S 4 Y 7/ 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
Aitach ivell consiniciion record(s)ifavallable.For multiple by'ection or non-water supply wells
OA'LY svirl;the same constnrctlonlabondonmew,you can submit one forms
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,
6,b.Total well depth. (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
L/ 10b.For Injection Wells: In addition to sending the form to the address in 10a
6.c.Borehole diameter: (in.) above,also,submit one copy of this form within 30 days of completion of well
abandonment to the following:
1 Division of Water Resources;Underground Injection Control Program,
1�Gd.. ater level below ground surface: �0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
qt
ft.) 10c.For Water Supply&Inieciion Wells: In addition to sending the form to the
6c.Outer casing Ieneth(if known): ( ) address(es)above,also submit ohe 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 or known): (fL) abandoned.
6'g.'Screen length(if known): (ft.)
Fnrm GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2.22-2016