Harnett_Well Abandonment_20221208

I.
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned: 4
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Calcium Hypochlorite
2.Well Construction Permit#: Harnett Co. app# EH2211-001
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.)ifknown , 8 oz.
7d.Amount of disinfectant used:
3.Well use(check well use): r
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout j ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) A Concrete Grout „ ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery —
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 5 cubic yards
❑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 Filled well void completely with concrete to
❑Geothermal(Heating/Cooling Return) ❑Other(e p a nitldz 7g)"n? f• --
within 3 feet of land surface where a 18"
4.Date well(s)abandoned: 11/22/22 DEC 0 8 2022 thick concrete plug;was installed on top.
5a.Well location: )R§rC;i ' D7 f MC*ag,�Uri;+
NC DOT N/A c1,A;Q/'3o
h
Facility/Owner Name Facility lD#(ifapplieable) 8.Certification:
4844 NC Highway 55 / � 11/22/22
Physical Address,City,and Zip Signature of Certified Well Contractor,'or Well Owner Date
Angier, NC 27501 0682-67-2411
By signing this form, 1 hereby certify that the well(s) was(were)abandoned in
p County fn47� Parcel Identification No.(PIN) accordance with 15A NCAC 02C;.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
/ and that a copy of this record has;,been provided to the well owner.
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(ifwell field,one latAong is sufficient) 9.Site diagram or additional well details:
35.473460 N 79.710279 W You may use the back of this pageito 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
41!x:k !.(eays;�%t:onrecord(s)ifavailable.For multiple itjec!ionornon-watersupplywells
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
62.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (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: 24 (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 25 (fL) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): N/A (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 cotinty health department of the county where
6L Inner casing/tubing length(if known). NIA (ft) abandoned.
6g.Screen length(if known): N/A (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division-of-Water Resources Revised 2-22-2016