Iredell_Well Abandonment_ (2)

WELL ABANDONMENT IZECORI)
for Internal Use ONhI';
I.Wets Conh actor Information: WELL ABANDONMENT I)E'1'AILS
NE'ILL PARDUE
_ 71.For Geoprobe/DI'T or Close(1Loop Geothermal Wells having the sore
Well Contractor Name for cull owner personally abandoning well on his/Iterproper(y) well constl•uotion/depth,only I OW."36 is needed. lndicale TOTAL NUMBER oh
2609A wells abandoned:__--_.-_2_
NC Well Cunu•actor Certilieadidn Number 7b.Approximate volume of waten,renaining in well(s): -(gal.)
AIR DRILLING INC FOR WATER SUPPLY WELLS ONLY:
Company Nome Construction
oswp20224570 7c 'type of disinfectant used:
2.Well Cmh•nction Permit#: _
List all applicable well construction permits(i.e. U1C,County,Slate, Variance,etc)ifknown 12 CUPS
I PS
7d,Amount of disinfectant used; v V v7
3.Well use(chcelt well use):
Water Supply Wcll: 7e.Sealing materials used(check all that apply):
LjAgriculwral ❑Municipal/Public 0 Neal Cement Grout 9 Bentonite Chips orPcllets
I_1Gcothennal(1-leating/C:ooling Supply) AResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
i_Ilntlustrial/Cornmcrcittl ClRcsidenlial 1Vater Supply(shtu•c(I) 1 1 Concrete Grout I_I Drill Cuttings
Lalrrigation 1-1 Specialty Grout tJ Gravel
Non-Water Supply Well: ❑ 13cntonite Slurry ❑ Other(explain under 7g)
I_lNloniloring []Recovery
injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 38 BAGS
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
I.-] xperimental'I'cchnology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑"I'raccr 7g,i'rovide a brief description of the abandonment procedure:
( ) ( I �) POURED 38 BAGS OF B T.Q,NTI~ H� ?S�_
❑Geothermal I Icatin g/Coolin=Retum ❑Other cx Main under 7= f
4.Date well(s).abandoned: 11-23-2022 JAti p 4
5a.Well location:
PURPOSE REAL ESTATE GROUP InfomrjlVa r roc-ei 2: Uns
' Jr`Qj u
Facility/Owner Nance Facility IDI/(if applicable) 8.Certifnca ' •
104 SINGLE OAK DR,TROUTMAN,N.C. 28166 11-28-2022
Physical Adclrass,City,and%il; - v=��--------- -
Signalure ol'Certificd Well Contractor o W—,;C,Oomer pate
IREDELL 4760092453
/lv signing Ihis form, /lreruhv cerli%v that the tvell(s) teas (here) ubundolied in
County Parcel Identification No.(PIN) (lem dance with 1511 NCAC 02C.0100 or 2C.0200 1-Yell Construction.Struularrls
caul that ri Copp of this record has been provided to the well owner.
Sb.Latihulc end longitude in degrees/minutes/seconds or decimal degrees:
fil•well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35° 41 .126 N 800 49.095 `�, You finny use the back of this pagc;to provide additional well site details or well
abandonment details. You may also attach additional pages if.necessaty.
CONS'1'RUC'ITON immuLS OF WEI.L(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
aunt h well tense uerian rer•arrlt:)iJ'aruNaGle. l'or multiple injection or not-Enter supply trelLr
OAT1'wilh the same con.ro•nclion/ahatrdonment,you Can submit ono jbi.m.
10a, For All Wells: Submit lhis'I'orm within 30 days of completion of Well
6a.Well ID/h abandonment to the following:
(ih.'I'otol well depth: 160 Division of Water-Resources,Information Processing Unit,
(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter: 6 I0b, For Injection Wells: Ill addition to sending the form to the luldrcss in 10a
(inn,) above, also submit one copy of this form within 30 clays of completion of Wcll
abandonment to the following: i,
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1036 Wail Service Ccnlcr,Raleigh,NC 27699-1636
I
6e.Outer casing length(it'knowu); (ft.) 10c.For Water Supply S Injection;Wells: In addition to sending the form to the
address(es)above,also submit one copy of'this Firm within 30 days of completion
of well abandonment to the cow ity health department of the county where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) i
C
Dorm GW-30 North Carolina Department of Eaviroomental Quality-Division of Water Resources Revised 2-22-2016
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