Stanly_Well Abandonment_20230213

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WELL ABANDONMENT RECORD ForinteralUseONLY: Ctp 1 ����
This form can be used for single or multiple wells f lJ
1.Well Contractor Information: "- ' WELL:ABANDONMENT DETAILSI'iviw:i3wC1 prlrC. tl UOt
Dwight L. I"1u11eycutt I . .'' 7a.Number of wells being abandoned:
Weil Contractor Name(or Well owner personally abandoning well on his/her property) For multiple injection or non-water] Isuppty wells ONLY with the' same
construction/abandonment,you can submit one form.
4070-A• ' .. • ; i .
NC.Well Connector Certification Number ; "''' --• 7b.Approximate volume of water remaining in well(s): 2 (gal.)
Derry's-Well Drilling,-Inc. FOR WATER.SUPPLY WELLS ONLY:
li
Company Name • • •
7c..Typeofdisjnfectantused:
Granular
I
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection etc.)if known 7d.Amount of,disinfectant used:
"1/2 lb.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): -•• .- --- -
• ❑Agricultural ❑Municipal/Public 0 Neat,Cement Grout ; RI Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I 0 Dry Clay
❑IndustriallCommercial ❑Residential Water Supply(shared); .❑•Concrete Grout 0 Drill Cuttings
❑Irrigation .❑•_Specialty Grout • • 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
▪Monitoring ❑Recovery
Injection Well: ; :7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge . . . . ❑Groundwater Remediation ;• 1.5"Gallons
❑Aquifer Storage and Recovery. • :❑Salinity Barrier •
❑Aquifer Test ❑StormwaterDrainage 50-1bS. -ChrpS
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❑Experimental Technology' ' ❑Subsidence Control 7g;Provide a brief description of theiabandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer • ; -Abandoned in place. Well was pumped with bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) .-
' slurry-through a 1"tremie pipe extending down into
5/11/22 '
a.Date well(s)abandoned: well up..#o:approx. 3' below surface. Remaining portion
5a.Well location: :. -was gravity filled with bentonite chips.
City of Albemarle Landfill
Facility/Owner Name Facility ID/I(if applicable) ,' 8.Certification:
40592B Stony Gap Rd., Albemarle 28001 � � 12/13/22
Physical Address,City,and Zip -Signature of Certified Well Contractor okkellDwner Date
Stanly , ::
-B,y signing this form,I hereby certify1;that the well(s)was(were)abandoned in
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 well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
rt 30g3q( -'� IS 3 1 qc1 J You may use the back of this page to!provide additional well site details or well
�Q N + W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple.injection or non-water supply
wells ONLY with the same construction/abandonment,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 Resources,Information Processing Unit,
18.59 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) I'
10b.For Injection Wells: In addition to sending the form to the address in l0a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 6 Om) abandonment to the following:
• Division of Water Resources,U I d I rground Injection Control Program,
6d.Water level below ground surface: 8.8 • (ft-) 1636 Mail Service Center;Raleigh,NC 27699-1636
10c.For Water Supply&Injection 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
where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): 15 (ft.)
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Reso ces Revised August 2013

# 9—Well Diagram 2" Well;Diameter
(Well # 1) - ( . .
- 2'' of casing and concrete
slab was removed from
well site.
0' to 3' Filled with . . ► ,,,,,,
Bentonite Chips -
erWri
3' to 18.5' Pumped
VNININ/w. with Bentonite Slurry
18.5' —Total Well Depth