Yadkin_Well Abandonment_ (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
C - 4421 construction/abandonment,you can submit one form.
1.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):_(gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: �':
List all applicable well consiruction permits Q.e.County,State,Variance,eic.)ifknown 7d.Amount of disinfectant used 4
3.Well use(check well use): A.IJ r . l'
Q a s 22�
Water Supply Well: 7e.Sealing materials used(check all that apply): ,
❑Agricultural ❑Municipal/Public
❑Neat Cement Grout IrWDRcnt4ititQ 04ipgor Fell, sUni!
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry&l Y'`a`
❑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)
91 Monitoring ❑Recovery
Injection Wcll: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 7.25 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: 06/04/22
5.1.Well location:
WEST YADKINVILLE GROCERY
Facility/Owner Name Facility ID#(if applicable) S.Certifcation:
4420 OLD US 421 HAMPTONVILLE 27020 `TM'r"'`� 06/15/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
YADKIN By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
360 07' 19.78" 800 47' 13.18" 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)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonmeni,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 45.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
2.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface 35.5 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6f:Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (170
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013