Randolph_Well Abandonment_20221222

WELL ABANDONMENT RECORD For loomed Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 7s.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personalty abandoning well on his/her proper_ well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
_ L wells abandoned.
4330-B
r •i 7~
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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CATLIN Engineers and Scientists ncC tl LL FOR WATER SUPPLY WELLS ONLY:
Company Name D•>+ S'✓ot`
at
#a,:C� � 7e.Type of disinfectant used:
2.Well Construction Perrot#: NA ID• r,�a:a35
oG
Lur all applicable well mmtrunton permlb fre.UIC,County,Swan,Yarwnre.ew)tJbrown
7d Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultuml ❑Municipal/publle ❑Neat Cement Grout III Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
Dlndustrial/Commencial DResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
Olffigation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: O Rectorate Slurry ❑Other(explain under 7g)
!!Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
[]Aquifer Recharge DGroundwater Remediation Bentonite Pellets —45 lbs
[]Aquifer Storage and Recovery ❑Salinity Barrier
[]Aquifer Test ❑Stormwater Drainage
❑Experimental Technology DSubsidence Control 7g,provide a brier description of the abandonment procedure:
OGeothermal(Closed Loop) OTracer
OCseothermal(Heating/CoolingReturn) DOther(explain under 7 ) Approximately 6 inches of casing removed, remainder
of well material abandoned in place with hydrated
4.Date well(s)abandoned: 11/25/2022 bentonite pellets to within 6 inches of surface and
5a.Well location: topped with surrounding soils from site to existing grade.
NCDEQ-Archdale Produce NA /)
Facility/Owner Name Faciity lD#(if applicable) S.Certification: /r -/-}-//
10425 S. Main St. Archdale, 27263 12/19/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph NA By signing this form. 1 hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constructton Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/mconds or decimal degrees:
(ifwell field,one Iallong is sufficient) 9.Site diagram or additional well details:
35.896040 N -79.941202 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 WELLISI BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach uellcoortruetionremrd(s)jmndahle. Formulnpkm)ectmnornon-matersupply uclh
ONLY uarh 1&,ame canstrumuut ahaminnmem,you can suhma onefrm. 10a. For All Wells: Submit this form within 30 days of completion of well
6s.Well lD#: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 29 (fit) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in.) above,also submit one copy of this form within 30 days of completion of Well
abandonment to the following:
6d.W'ater level below ground surface: 16.16 (R.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (fL) 10c.For Water Suonh&Infection Wells: In addition to sending the form to the
addresses)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): 14 (ft.) abandoned.
6g.Screen length(if known): 15 (n.)
Form GW-30 North Carolina Department of Envbonmental Quality-Division of Water Resources Revised 2.22-2016

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TMW-02
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TMW-01
MW-01
LEGEND
• Abandoned Monitoring
Well (Type II)
® Abandoned Monitoring
Well (Temporary)
e-
OApproximate Location
of Former UST Basin
❑ Parcel BoundarySource-_Es i r. a 'eograp c an 'se o,
NOTE:Well and tank location were obtained from previous
reports prepared by other consultants and are approximate. 50 25 0 50 too
Feet
r WKT TILE FIGURE
A�ARCHDALE, NC
SITE MAP
CATLINPRODUCE
Engineers and Scientists
-NANO ABNO. aiE B u` OIUWNBYILM Br
16114 220288 DEC 2022 AS SHOWN IQ4CIC/SJO