McDowell_Well Abandonment_20221014

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Jeff Garlock 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nam(or well owner personally abandoning well on hwher Property) well construction/depth,only l GW-30 is needed. Indicate TOTAL NUMBER of
3392-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Blue Ridge Geological Services FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit s: 55-0124-WM-0050 O C T 1 2022
Liv all ap/rlicable x e//,,,m,mIms permils O.a.111r1 County,Scale,Variance,etc.)i inamn
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 a Bentonite Chips or Pellets
❑Geothermal(Herring/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
Olicrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: O Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7E For each material selected abuse,provide amount of materials used:
OAquifer Recharge OGroundwater Remedialion 1/4 bag bentonite pellets
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 1/4 bag cement
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
OGeothenmd(Closed Loop) OTracer
OGeothermal(Hearin Coolie Remm) OOther(explain under 7 ) poured bentonite pellets into PVC pipe to near ground surface,
poured cement into and around top of PVC
4.Date well(s)abandoned: 7/8/2022
52.Well location:
Crane ChemPharma
Facility/Owner Name Facility IDa(ifappliwble) 8.Ctr M
1 Quality Way, Marion, NC 28752 7-14-2022
Physical Address,City,and Zip Signatur(olfCcrifiell Well Contractor or Well Owner Due
McDowell 0781-02-87-9732
By signing this form. 1 hereby certify that the well(s) was (were) abandoned in
Comfy Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 1C.0100 Well Construction Standards
and that a copy of this record has been provided io the well owner.
Sb.Latitude and longitude in degrees/minules/seconds or decimal degrees:
(ifwcll field,one ImAong is sufficient) 9.Site diagram or additional well details:
35 deg 41'00.7" N -82 deg 04'00.6" W, You may use the back of this page m provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF VPELLIS)BEING ABANDONED SCBMITTAL INSTRUCTIONS
Allach xe/lconslrt¢lian recoilny{lmoiluhle. lirr rmduple in/e<'n"n orrmn-watersupply wells
ONLY v4lh the name consanrnon abandonment,v,m car submit aneJorm.
[On. For All Wells: Submit this form within 30 days of completion of well
62.Well IDa: MW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (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: 8 (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: 12 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
be.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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): 3 00 abandoned.
6g.Screen length(if known): 10 (R)
Fonn G W'-30 North Carolina Department of Hnvionacamal Quality-Division of Water Resomccs Revised 2-22-2016