Iredell_Well Abandonment_ (6)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.*ell Contractor Information: WELI,ABANDONMENT DETAILS
NEILL PARDUE I
7a.For Gcoprobe/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
2609A wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water emaining in well(s): (gal.).
AIR DRILLING INC i '
FOR WATER'SUPPLY WELLS ONLY:
Company Name i
33b689 7c.'rype of disinfectant used: HTH
2.Well Construction Permit 11: '
List all applicable well construction permits(i.e.U/C,County Slate,Mar•iance,etc.)iflurowrr 2 CUPS`
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a Bentonite Chips or Pcllets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ration ❑ Specialty Grout ❑ Gravel
Non-Wafer Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Rccovcry
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 22 BAGS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwatcr Drainage
❑Gxperimental Technology ❑Subsidence Control
7g.Provide a brief description of,the abandonment procedure:
❑Gcothernal(Closed Loop) ❑Tracer POURED 22 BAGS OF BENTONITE CHIPS
❑Geothermal(1lcating/Cooling Return) ❑Other(explain under 7g)
S;,
1 Y]
d.Dale wells)abandoned: 10-5-2022
5a.Well location:
JEREMY PLYLER
Facility/OwnerName 1119v1�4t�n:11
Facility ID/I(if applicable) 8.Certilicati
133 OVERCASH RD,TROUTMAN,N.C. 28166 _ #17- AV Ile Z4510-5-2022
Physical Address.City,and Zip Sig rc of cru hcc Well ontmctor o Well U+ Date
IREDELL 4751711040
13y signing this form, 1 hereby certify that the well(s) was (urre) abandoned in
County Parcel identification No.(PIN) accordance with 15A NCAC 02C:b100 or 3C.0200 i cdl Collsir•Ircliorl Stalltlards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds of decimal degrees:
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
350 41.387 N 80- 49.689 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 iCncccssary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANllONED SUBMITTAL INSTRUCTIONS.
Anac/r u•cllc•onstrnr•tion rec•mrrl(s)if availab/e. Fornr«(liple injection ornon-rratcrsupph'we/fr
ONLY with tie same consurteliarh/obarrdonmherhi,you can suhmil one firm.rm.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.'1'otal well depth: 120 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1
10b.For In*ection Wells: In addition to sending the fonn to the address in 10a
6c.Borehole diameter: 5 (;n,) above, also submit one copy of this forni within 30 days of completion of well
abandonment to the following: i
i
6d.Water level below ground surface: (ft,) Division of Water Resources,!Uhderground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(ir known): (ft.) I0c.For Water Suanly Sc iniecti n'Wells: In addition to sending the fonn to the
address(es)above,also submit and cppy 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,
i
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016