Chatham_Well Abandonment_20221021

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Lamont Green 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
4468-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Charles R. Underwood, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)fknown 2.5 Ibs 1 7 2022
7d.Amount of disinfectant used: �T f
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that appjp3 nkav� tlfr;4
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite K11ps or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) R Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7 )
❑Monitoring ❑Recovery `11 (En
u t
Injection Well: 7E For each material selected above,provide amo a stFd. �'
❑Aquifer Recharge ❑Groundwater Remediation 7 bags of Bentonite Chips OC T 2 1 2022
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 2-94 lb bags of concrete 1"i
❑Experimental Technology ❑Subsidence Control 00
7g,provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Plumbing,Piping and pump was already removed from well prior to ownership.Block Pumphouse was taken down.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Well was disinfected with 2.5 Ibs of HTH.Area around casing was dug up with backhoe to 3.5'deep and 2'x2'area.
4.Date wells abandoned: 1 0/1 2/2022
O Casing was cut off to 3'below grade. Well was filled with Bentonite chips to top of casing.
$a.Well location: Concrete was poured into the entire dug area around and above the well rasing. Area was leveled.
C.M. Underwood
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
15881 US Hwy 421 S, Sanford, NC 27330 ,, y,_, /0-iZ�2oz�
Physical Address,City,and Zip SijKature of Certified Well Contractor or Well Owner Date
Chatham 0068862
By signing this form, /hereby certify that the tvell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
Sb.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:
N W 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,ellconstructionrecord(s)ifavailable. Fornudtipleinjectionornon-watersupplyw,ells
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#: Unknown abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 94.6 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6.5 (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: 28 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Suooly&Iniection 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
6E Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): Unknown
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016