Davie_Well Abandonment_20221216

WELL tBANI)ONMEIN it I-MUO" IFor Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Ronald F. Barron 7a.For Geoprobe/DPT or Closed-&op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandonin&w,ell,ohhis/her•propepy)" —o. well construction/depth,only 1 GW-30 lis needed. Indicate TOTAL NUMBER of
2091-A -m° wells abandoned:NIA
5 hcy
NC Well Contractor Certification Number D�(� r 2Q22 7b.Approximate volume of water I emaining in well(s): (gal.)
Piedmont Industrial Services l• llr�d `FOR WATER SUPPLY WELLS ONLY:
Company lnii✓Pfes'*�
P y Name or�ty� 7c.Type of disinfectant used: NA
2.Well Construction Permit#: 3$0695
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: ;NA
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) eResidential Water Supply(single) ❑ Sand Cement Grout I ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) s Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry a Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1 cubic yard concrete
❑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 I
Davie county well abandorimen# permit#380695.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Well abandoned in accordance with;attached variance approval number.JMB2757
4.Date well(s)abandoned:
5a.Well location:
Joseph Miles N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
244 Jesse King Road, Advance, NC, 27006
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner bate
Davie 5863477091 By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
N _8b��8 Z �+ 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
Attach well construction records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: #244 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (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: 22 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
N/A Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: Vt.)
1636 Mail Service Center,Raleigh,NC 27699-1636
I.
N/A 10c.For Water Supply&Infection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.)
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): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.) j
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water ResoureI s I Revised 2-22-2016
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Well Abandonment For OfficelUse Only
Davie County
298 E Depot St CDP File Number: 380695-1
County ID Number: 5863477091
Mocksville,NC 27028 Evaluated For: WELLABANDONMENT
33.6-753-6780 -
PERMIT VALID UNTIL: I
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Property Owner: Joseph Miles Applicant: Joseph Miles
Address: 330 Pebblestone Court,244 Jesse King F Address: 330_Pebblestone'C6urt;
City: Lexington City: Lexington i,_
State/Zip: NC/272.95 State/Zip: NC/27295 I'
Phone#: [phone] Phone#: [phone] !'
Drillin Contractor: Location:
Latitude: Ltd'g!o'7 b z T-S"
Driller Registration: Longitude: �`Be ZB`7-'
Well:.
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Type: BORED Nearest Structure: 15 Ft
Fill Material Material: Method:
Total Depth: 40 Ft From: Ft To Ft N/A N/A
Diameter: 22_ In. From: Ft To Ft N/A NIA
Static Water: Ft. From: - Ft To Ft N/A N/A
Water Removed: NO Date of Issue: 09/19/2022
Plumbing: N/A
Cement Plug At:
Well Grouted: N/A i
From: Ft To 0 Ft
Casing Removed: Ft
Comments:
Issued By: Naylor, Emil(20 j Applicant/Legal Signature:
Total Time:
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