Davidson_Well Abandonment_20230327 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bruce Keith Braswell 7a.For Geoprobe/DPT or Closed-Loop Geotberatal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/lier property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
3304-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Phoenix Environmental, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Bumout 73
7c.Type of disinfectant used: Calcium H_ � YpoctltXde)
2.Well Construction Permit N:
List all applicable well construction permits(le.UIC,County,Slam,Variance,etc.)if known
7d.Amount of disinfectant used: 1 lb
3.Well use(check well use):
Water Supply Well: 7t.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ■Concrete Grout ❑Drill Cuttings
❑Irrigation a Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Benionite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amouulp(=Utt"*-C'
❑Aquifer Recharge ❑Groundwater Remediation Specialty Grout- 1.25 yd
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquifaTest ❑StormwaterDrainage Concrete- .3 yd _ MAR 2 7 2023
❑Experimental Technology ❑Subsidence Control
❑Geothermal( ) ❑T�Cef �, . ,.•�:� 'tr
Closed 7g Provide a brief description of the abandonmealri#ole2dil : '
Well filled with 1.25 yd3 of small gravel gr0u6 W' h`1%
❑Geothermal (Heating/Cooling Return ❑Other(explain under 7 )
bentonite. Casing pulled and area 1'beyond the casing
4.Date well(a)abandoned: 3-14-23
excavated to>36 . Form set and a 6 thick pad poured
52.well location: with 4000 psi sakrete rnix.
Cheyenne Sluder
Facility/Owner Name Facility 11M(ifapplicable) 8.Certification:
700 Lexington Avenue, Thomasville NC 27360 Js � L 3-- ► Li-,?3
Physical Address-City,and Zip 9Ignsturc of Certified Well Contractor or Well Owner Date
Davidson 16031000B0001 -signing this orin, I hereby terry' that the wells was
By S 8 f y h' () (were)abandoned in
County Parcel Identification No(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Consowtion&andards
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.
(ifweli field,one IatAong is sufficient) 9.Site diagram or additional well details:
30 52' 54.34" N -80 6' 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 necessary.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Alta h u,rll cvnarrnwfmn records)ttfavailable. l,or mulnp/e injectkw or non-mwier supph,u el/c
ONLY with the same construction ahamlonotent.you can submit tine farm.
lOs. For All Wells: Submit this Ibrm within 30 days of completion of well
6a.WeN IDN: abandonment to the following:
21 78 Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft) 1617 Mail Service Center,Raleigh,NC 2709-1617
10b.For Injection Wells: In addition to sending the foam to the address in 10a
6c.Borehole 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 00 Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276W1636
6e.Outer casing length(if known): Unknown (ft) 10c.For Water Suooly&Infection Wells: 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 department of the county where
6E Inner casing/tubing length(if known): Unknown A) abandoned.
6g.Screen length(if known): Unknown (ft.)
Form GW-30 North Carolina Department of Fm•ironmental Quality-Division of Water Resources Revised 2-22-2016