Alamance_Well Abandonment_ (9)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Scott M. Werley 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 I GW!30 is needed. Indicate TOTAL NUMBER of
3344—A wells abandoned:T—(2)
NC Well Contractor Certification Number 7b.Approximate volume of water'remaining in well(s): Dry (gal.)
ECS Southeast, LLP FOR WATER SUPPLY WELLS QNLY:
Company Name
2.Well Construction Permit#:
WM0401385 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.)ifknown
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 N Neat Cement Grout a 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
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRetriediation Bentonite — 20 Ibs Neat cement-25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description oft he abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Feed bentonite chips from 45' - 5' bgs
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7e)
v our neat cement from 5' bgs to surface
4.Date well(s)abandoned:
8/9/2022 F., v,
Sa.Well location:
AUG 2022
Facility/Owner Name Facility ID,(if W'"L 8.Certification:
1865 E Buckhill Road, Burlington, NC ( ' d 8/12/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or' ell Owner Date
Alamance 8844507669
By signing this form. 1 hereby certify that the irell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well oumer.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 9.Site diagram or additional well;ldetails:
N VV 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
Attachu,ellconvtructiorrrecord(s)ifm,ailable.For multiple injection ornon-watersupplywells
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#: TW-2 and TW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.25 (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• d'7r�� (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 30 —(ft.) 10c.For Water Supply&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): N/A (ft.) abandoned.
i
6g.Screen length(if known): 15 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016