Rowan_Well Abandonment_

WELL ABANDONMENT RECORD
For Internal Use ONLY:
I.Well Contractor Information:
WELL ABANDONMENT DETAILS
CHAD HARTNESS
7a.For Geoprobe/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're"maining in well(s): (gal,)
AIR DRILLING INC FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
366288-3 7c.Type of disinfectant used: HTH
List all applicable well construction pen nits(i.e.WC,County,State,Variance,etc.)ifknosvn
7d.Amount of disinfectant used: 2 CUPS
3.Well use(check well use):
Water Supply Well: 7c.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout
e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 012esidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout
❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:
❑Monitoring ❑Recovery ❑ Bentonite Slurry ❑ Other(explain under 7g)
Injection Well: 711 For each material selected abobc,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remedialion 50 LBS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) POURED 50 LBS BENTONITE CHIPS
4.Date wells)abandoned: 2-2-2022 ^"
Sa.Well location:
DARRIN PASCHAL JAN 0 4 2023
Facility/Owner Name Facility lD#(if applicable) 8 ert' ation:
.7l s
u,
130 WHITE RD, SALISBURY,N.C. 28147
Physical Address,City,and Zip
2-2-2022
Signature of Certified Well Contractor or Well Owner Date
ROWAN 770033
County By signing this form, 1 hereby certify that the well(s) was (were)abandoned in
Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of This record has been provided to the well owner.
(if well field,one]at/long is sufficient)
35° 38.546 9.Site diagram or additional well details:
N 80° 38.115 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
Attach svell construction record(s)ifavailable.Fornu1Ctiplei4ecdonornon-watersupplywells SUBMITTAL INSTRUCTIONS
ON/,Y with the same carstraclion/abandanmeul,you can submit one fora+. �
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Gb.Total well depth: 22 Division of Water Resources,Information Processing Unit,
(ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Gc.Borehole diameter: 2 lob. 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:
6d.Water level below ground surface: (ft,) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Sunnly&Infection Wells: In addition to sending the form to the
address(cs)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
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources'
Revised 2-22-2016