Randolph_Well Abandonment_20230113

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS'
JAMES MORRISON 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on Iris/her property) For multiple injection or non-ivater, supply hells ONLY with the same
construction/abandonment,you can submit o,e form.
C - 4421 2.5
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#: )
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknouw ]d.Amount of disinfectant used A 1, a�
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3.Well use(check well use): _ { 0 202a 3�
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7e.Scaling materials used check all that apply):
Water Supply Well: g ( '''_�•:�
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Cljipbor,Pellt;ts.;,
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 2) Bentonite Slurry ❑ Other(explain.under 7g)
MMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 6.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/24/22
5a.Well location:
QUALITY FABRICATORS
Facility/Owner Name Facility iDU(if applicable) 8•Certification:
170 PARKS CROSSROADS CHURCH RD RAMSEUR 27316 " 11/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
RANDOLPH By signing this form, i hereby certify that the ivell(s)ivas (were) abandoned ill
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 9.Site diagram or additional well details:
350 44' 36.45" 790 34' 46.22" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-waier supply
wells ONLY with the same construction/abandomnew,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Quality,Information Processing Unit,
fib.Total well depth: 40.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface 25.5 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
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6f.Inner casing/tubing length(if known): (ft.) where abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013
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