Iredell_Well Abandonment_20221021

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
N E I LL PARD U E 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoningwell on his/her property) Well consttuctioh/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2609A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
AIR DRILLING I N C FOR WATER SUPPLY WELLS ONLY:
Company Name
2022-5744 7e.Type of disinfectant used: HTH
2.Well Construction Permit#..
List all applicable well construction permits(i.e.UIC County,State, Variance,etc.)ifknown 2 CUPS
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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) GResidential Water Supply(single) ❑'Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) M Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Reme.diation 1 .25 YARD
❑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 POURED 1.25 YARD CONCRETE
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date.well(s)abandoned: 10-11-2022
OCT 2 i 2022
5a.Well location:
JSMITH CIVIL,LLC 0 UM
' .,,�% �Vb'QIP3
Facility/Owner Name Facility 1DN(if applicable) 8.Cc, OG_/•
201 GRESHAM LANE,MOORESVILLE,N.C. 28117 e 10-11-2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
IREDELL 4637982469
By signing-this form, I hereby c•erti&that the well(s) uas(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 well owner.
5b.Latitude aril longitude in degrees/minuteslseconds or decimal degrees:
(if well field,one]at/long is"sufficient) 9.Site diagram or additional well details:
350 35.948 N 80° 53.171 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 A13ANDONED 'SUBMITTAL INSTRUCTIONS
.4nachtrellcmxstructionrecord(s)ifavailable. For multiple injection or non-walersupplyice4s
ONLY with the some construction✓abandonment,you can submit one form
10a. For All Wells: Submit This form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 125 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For lniection Wells: In addition to sending the form to the address in 10a
6c..Borehole diameter• 6 (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: {t) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
addres-s(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): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Rcvised 2-22-2016