Yadkin_Well Abandonment_ (3)

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 sale
C -4421 construction/abandonnhent,you can submit one fornt.
7b.Approximate volume of water remaining in well(s): 1.5 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name _.-,j *°q ,i r 7e.Type of disinfectant used: L s' .,
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown U Q
7d.Amount of disinfectant used: AUG G 7 ., :r'a 702
3.Well use(check well use): _
7e.Sealing materials used check all t�alt a rpIj) %,,Cy6L,� URii
Water Supply Well: g ( PP Yjn�t�ti;G}tt?v
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) El 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: 171 Bentonite Slurry ❑ Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 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
5a.Well location:
WEST YADKINVILLE GROCERY
Facility/Owner Name Facility ID#(if applicable) $•Certification:
4420 OLD US 421 HAMPTONVILLE 27020 """" 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 ivell(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 t is record has been provided io the Nell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
360 07' 19.91" N 800 47' 12.24" You may use the W abandonment details. Youack of tma Palso attach e to additionalde additional well site s f nee scary. or well
Y pages necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. 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-3 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:
38•0 Division of Water Quality,Underground Injection Control Program,
Gd.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to
Ge.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): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013