Iredell_Well Abandonment_ (8)

WELL ABANDONMENT RECORD
For Internal Use ONLY:
I.Well Contractor Information: WELL ABANDONMENT DETAILS
N E I LL PARD U E 7a.For Geoprobe/DPT or Closcd Ldop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 430 is needed. Indicate TOTAL NUMBER of
2609A wells abandoned:
NC Well Contractor Certification Number 76.Approximate volume'of water Jremaining in Wcll(s): (gal.)
AIR DRILLING INC '
FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
325285 7c.Type of disinfectant used: HTH
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.)ifkhowa 2 CUPS
r7 C�
7d.Amount of disinfectant used: C U f_S
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
� PP Y):
❑Agricultural ' ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(}!eating/Cooling Supply) NResidcntial Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑ n Galion ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry
❑Monitoring ❑Recover ® Other(explain under 7g)
Y
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 21 BAGS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothemtal(Heating/Cooling Return) ❑Other(explain under 7g) 21 BAGS H O L E P L U G (POURED)
05-20-2022 rn�' 'N__ '_ 4
4.Date wcll(s)abandoned: tl +A.— —a V k_r.w
5a.Well location: JAN 0 -
PRINCETON HOMES
Ulls
Facility/Owner Name Facility IDN(ifapplicable) 8.Cerli o 136 FLATROCK LAN E,STATESVILLE,N.C. 28677 05-20-2022
Physical Address.City,and Zipnatur of e t Rd ell ontmc r or 7 c Date
IREDELL 4725461447
py signing this farm, I hereby certify that the well(s) was (were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 IVell Construction Slandards
and that a cape ofthis record has beeii provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) I•
0 9.Site diagram or additional well details:
35 48.534 N 80° 55.310 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
Annchwellron.coonttnnrecorrl(,)iJ'nvuilnble. For•multiple iryectiorraruarr-❑atersnpply veils j
ONLY with the same cnnsiruction/abordourneat,you can submit one foam.
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,
6h.'1'otal well depth: 10 0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
6c.Borehole diameter: 6 10h. For Infection Wells: In addition to sending the form to the address in 10a
(in,) above, also submit one copy of this'form 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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6c.Outer casing length(if known): (ft.) 10c.For Water Supply S Iniection Wells: In addition to sending the form to the
addresses)above,also submit one copy pf this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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