Randolph_Well Abandonment_20230227

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WELL ABANDONMENT RECORD For fntemal Use ONLY: is
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 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 I3011 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned: I I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLSIONLY:
Company Name 7c.Type of disinfectant used: HTH Chlorine (.. ' "r`'',F,e
6:"
2023-00000072 ' ''�LeL: •
2.Well Construction Permit#: it
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known �'""(i
7d.Amount of disinfectant used:.7 oz Firs 2 7 l n?
3.Well use(check well use): J
Water Supply Well: 7e.Sealing materials used(check all that apply): 'rrl"N`5---- ' i'7."-- r
Dtrr r,,,, 0 Una
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout I: 0 Bentonite Chips ol• a le
' 0 Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ❑ Sand Cement Grout s Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) U Concrete Grout ❑Drill Cuttings
11
❑Irrigation• 0 Specialty Grout ' 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry • 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge • ❑Groundwater Remediation Concrete grout 0.75 yds3
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Dry Clay 2.5 yds3
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description ofithe abandonment procedure:
❑Geothermal(Closed Loop) OTracer !t
0 Geothermal(Heating/Cooling Return) ❑other(explain under 7g) Poured concrete directly into well and filled to
• within 3 feet of land surface. Concrete cap put
4.Date well(s)abandoned: 2-9-23 on top of filled well approximately 18 inches thick.
5a.Well location:
Klaussner Furniture Industries N/A
Facility/Owner Name' Facility ID#(if applicable) 8-Certification: ii
1800 US Highway 64 E. Asheboro, NC 27203 i 2- 4.04
AZ957- 4 2-9-23Physical Address,City,and Zip Signature of Certified Well r or ell Owner Date
Randolph 7761912926 By signing this form, I hereby ce'rrt&that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1.5A 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: l; '
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.705547' N 79.778100' 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
Attach well construction record(s)ifavailable.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 TMSW 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 17 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1013.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
6a Borehole diameter: 24 (in.)
abandonment to the following:
Unknown Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
Unknown 10c.For Water Supply&Iniectio I Wells: In addition to sending the form to the
tie Outer casing length(if known): (ft.) 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): Unknown (ft.) abandoned. I'
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016