Montgomery_Well Abandonment_20220817

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WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
NICHOLAS HAYES 7a.Number of wells being aband I ed: 1
Well Contractor Name(or well owner personally abandoning well on)iis/her$roparl}c)� n, Z multiple injection or non-water supply wells ONLY with the same
y A o trucnon/abandonment,you can submit one form.
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ZQ2� 7b.Approximate volume of water`remaining in well(s): (gal.)
NC Well Contractor Certification Number '1 r 1, f
GEOLOGIC EXPLORATION, INC p'J 3 FOR WATER SUPPLY WELLSi'ONLY:
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Company Name Inf V Irf, "� ' '` �C 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ijknown 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) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 1.25 GALLONS
❑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 ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 06/29/22
5a.Well location:
BROWNFIELD ASSESSMENTS
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
175 SOUTH WADESBORO BLVD MT GILEAD 27306 07/11/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
MONTGOMERY By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
350 13 06.06' 80 00' 23.12 You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS'
Attach well construction record(s)ijavailable. For multiple injection or non-water supply
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#: MW-14 abandonment to the following:
Division of Water Quality,Information Processing Unit,
8.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'O (in.) abandonment to the following:
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6d.Water level below ground surface 5.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suomav&Iniection Wells: In addition to sending the form to
the address(es) above, also submit gone copy of this form within 30 days of
completion of well abandonment to,the county health department of the county
where abandoned.
6E Inner casing/tubing length(if known):
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013