Davidson_Well Abandonment_20230327

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL.ABANDONMENT DETAILS
Bruce Keith Braswell 7a.For Geoprobe/DPT or Closed-Loop Geotkertml Welk having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3304-A Hells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in wtll(s): (gal.)
Phoenix Environmental, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Bumout 73(Caldum Hypoetlloflte)
1.Well Construction Permit N:
List aB applicahk well construction permits f.e.(11(',County,Srate.Variance,etc.)if known
7d.Amount of disinfectant used: 1 lb
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑Bentonite chips or Pellets
❑Geothermal(Heating/Cooling Supply) e1kesidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ■Concrete Grout ❑ Drill Cuttings
❑Irrigation N Specialty Grout ❑Gravel
Non-Water Sapply Well: ❑ Bentonite Slurry ❑Odrcr(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amnaptalinateriakamil:
❑Aquifer Recharge ❑Groundwater Remediation Specialty Grout- 1.25 yd
❑Aquifer Storage and Recovery ❑Salinity Barrier —
❑AquiferTest ❑StormwaterDrainage Concrete- .3 yd MAR 2 i 2023
❑Experimental Technology ❑Subsidence Control
7g Provide a brief description of the abandonmgotipeeea
❑Geothermal(closed Loop) OTracer Well filled with 1.25 yd3 of small gravel gt06t*th 2%
❑Geothermal Heatin Coolin Return) ❑Other(explain under 7 )
bentonite. Casing pulled land area V beyond the casing
4.Date wells)abandoned: 3-14-23 excavated to>36". Form set and a 6"thick pad poured
sa.Well location: with 4000 psi sakrete mix.
Cheyenne Sluder
Facility/Owner Name Facility IDN(ifapplicable) g.Certification:
700 Lexington Avenue, Thomasville NC 27360 Jim k�4 3 1 Y-,93
Physical Address.City,and Zip Signature of Catified Well Contractor or Well Owner Date
Davidson 16031000B0001
By signing this form. I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No (Pl.\) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constraetion Sratdards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner
(ifwell field,one Iavlong is sufficient) 9.Site diagram or additional well details:
30 52r 54.34" N -80 6r 0.94" 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 ncccssary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach we//atnrtructionrecords)ifmnilahle. harntuhtple injection orrun-waier.rupph•wells
ON/.Y with the same conaructirm abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDN: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 21.78 A) 1617 Mail Service Center,Rakigi,NC 27094617
10b.For taiecton Welk: In addition to sending the form to the address in 10a
6c.Borebole diameter: 18 (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: 8.20 (ft.) Division of Water Resources,Undergroaad Injtecdoo Control Program,
1636 Mail Service Center,Raleigh,NC 276W1636
6e.Outer casing length(if known): Unknown (ft.) 10c.For Water Supply&Iniecdon Welk: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health dcparhment of the county where
6E loner casing/tubing length(if known): Unknown (ft.) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016