Davidson_Well Abandonment_20230315

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WELL ABANDONMENT RECORD For Internal Use ONLY: '
This form can be used for single or multiple wells I '
1.Well Contractor Information: WELL ABANDONMENT DETAILS
JAMES MORRISON 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the saute
construction/abandonment,you can submit one form.
C - 4421 - ^� 183.0
f f ate i g
` 7b.Approximate volume of water remainingin wells al.
NC Well Contractor Certification Number PP O: (gal.)
GEOLOGIC EXPLORATION MAR 1 5 2023 FOR WATER SUPPLY WELLS ONLY:
Company Name _ 7c.Type of disinfectant used: GRANULAR CHLORINE
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State, riance,etc.)if known 7d.Amount of disinfectant used:
6.0 OUNCES
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 265.5 GALLONS
DAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothennal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 01/24/23 •
5a.-Well location: __ - -- - - - -- - - - --- -
COLONIAL PIPELINE
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
685 HELMSTETLER ROAD LEXINGTON 27295 02/01/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
DAVIDSON By signing this form, 1 hereby cerl.*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:
35° 48' 22.88" N 80° 19' 55.34" 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(%)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. I Oa. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#: WSW-2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
177.0 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b. For Infection Wells: In addition to sending the form to the address in IOa
6.0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: . 55.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply& Injection Wells: In addition to sending the form to
6c.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): • (ft.)
Form OW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013