Iredell_Well Abandonment_ (7)

WELL ABANDONMENT RECORD For Internal Use ONLY: j
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
CHAD HARTN ESS 7a.For Geoprobc/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
2901 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
AIR DRILLING INC FOR WATER SUPPLYWELLSIONLY:
Company Name 7
2.Well Construction Permit#:
323893 c.Type of disinfectant used: HTH
List all applicable well construction permits(i.e.UIC,County,State, flariance,etc.)ifknown 12 CUPS
7d.Amount of disinfectant used:i
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout M Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 21IResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ration ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 150 LBS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer POURED 150 LBS BENTONITE CHIPS
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well 09-12-2022s)abandoned:
5a.Well location: J A iy 0 4 26 D
TERESA GOODWIN
Facility/OwncrName FacilitylDll(if applicable) ye hficat p: f-� ;;g l ,wit 3Cz•w LrciS158 EMMANUEL RD,TROUTMAN,N.C. 28166 ---- _ '
09 12-2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
IREDELL 4751021575 � •
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.d100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds ordecimal degrees: and that a copy of this record has beers provided to the well owner.
(if well field,one lot/long is sufficient) 9.Site diagram or additional well(details:
350 41.371 N 800 51.063 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
Attnrhtrellraictructionrecad(.r)ifava/lab/e. Foruwltlplei�jectlonornon-wntersuppl�•we11s
ONLY with the same consn•uctia✓abamimrnient,you can submit one form.
10a. For All Wells: Submit this f6rn within 30 days of completion of well
6a.Well ID#• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 90 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.Outer casing length(if known): (ft.) 10c.For Water Supply&Inieclioh Wells: In addition to sending the fotni 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): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016