Iredell_Well Abandonment_ (5)

Pi WELL ABANDONMENT RECORD For Internal Use ONLY;
L.Well Contractor Information: WELL ABANDONMENT DETAILS
NEILL PARDUE
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Nanic(or well owner personally abandoning well on his/her property) well construction/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 INC FOR WATER SUPPLY WELLSONLY:
Company Name
2022-5744 7c.Type of disinfectant used: MTH
2.Well Construction Permit#: ,
List all applicable well construction permits(i.e.UIC Cotalq,,State,l'ariance-etc)ifknown 2 CUP C
7d.Amount of disinfectant used: CUPS
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) NResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) N Concrete Grout
❑ Drill Cuttings
❑Ini ration ❑ Specialty Grout ❑Gravel
Non-Water Supply Well:
❑Monitoring ❑Recovery ❑ Bentonite Slurry ❑ Other(explain under 7g)
Injection Well:tjAquifer Recharge ❑Groundwater Remediati°n 7L For each material selected above,provide amount of materials used:
1 .25 YARD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology OSubsidence Control
❑Geothermal(Closed Loop) []Tracer 7g•Provide.a brief description of the abandonment procedure:
❑Gcothcnmal(Heating/Cooling Return) ❑Other(explain tinder 7g) POURED 1.25 YARD CON CRETE. �, ,�..
10-11-2022 L-% V 4-,
4.Date well(s)abandoned: JTFO G 1
5
4
3
Sa.Well location:
JSMITH CIVIL,LLC Pr c.?a--%A3 Ural
Facility/Owner Name P
Facility ID#(ifapplicable) S.Cert'
201 GRESHAM LANE,MOORESVILLE,N.C.C. 28117
10-11-2022
Physical Address,City,and Zip Signature of Certified Well Contractor of Well Owncr
IREDELL 4637982469 1. Date
County By signing/his form, J hereby certify that the ivell(s) ivas(were)aban(oneet in
Parcel Identification No.(PIN) accorelance with ISA NCAC 02C.0100 or 2C.0200 Well Consltttctioll Statxlat•(Is
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees; and that a copy of 1his recazl has been provided to the well stoner.
(ifwell field,one hulong is sufficient)
35 35.948 9.Site diagram or additional well details:
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 ABANDONED i
illlaehnL'll('a/ISn4lCtlalU'eCOrd(S)faVallable. Far nluhiple,itycctioll 01, on-tt'(Ite l•sllppl)'ll'el/P SUBMITTAL INSTRUCTIONS;
ONLY with die some collsu•!letion/abandonnle/lt,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:
66.'I oral well depth: 125 Division of Water Resources,Information Processing Unit,
(ft.) 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: 6 (in.) above, also submit one copy of this forth within 30 days of completion of well
abandonment to the following: ;
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6d.Water level below ground surface: (ft.) 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): (ft.) I0c.For Water Supply&Injectio !n 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 county; health department of the county where
6f.Inner casing/tubing length(if known): (ft,) abandoned.
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6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i
Revised 2-22-2016