Stanly_Well Abandonment_20230419

.a SrAr ,
.3: WELL ABANDONMENT RECORA'
.yr :' Io: North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# r.'2 5(2 2
1.WELL CONTRACTOR: - 6. WELL DETAILS:
o d d A d al'vr1 S • a.Total Depth 8'41 ft. Diameter: 4, in.
Well C ntractor(Individual)Name b.Water Level(Below Measuring Point): 472 7 ft.
6 Weft' i►/n /Q (.S 0I i I;i Measuring point is i ft above land surface.
Well Contractor Compahy"Name
I1( R O ,Sh 0/(; (!5 fo id c‘i, 6. CASING: Length Diameter
Street Address
•
SC I, u ri Al— r028/y-7 a.Casing Depth(if known): ft. in.
City or Town
t n l State Zip Code b..Casing Removed: tig / ft. / in.
1 3 7
(e— 7'7 7. DISINFECTION: / d y—
A a code Pho a number
(Amount of 65%75%calcium hypochiorite used)
2.WELL INFORMATION: 8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
Neat Cement Sand Cement
STATE WELL PERMIT# (if applicable) aiii‘FCement lb. Cement lb.
ji/4, Water gal. Water gal.
COUNTY WELL PERMIT #(if applicable)
Bentonite
DWQ or OTHER PERMIT # if applicable) i� _
Bentonite ,3-G' lb. _
WELL USE(Check applicable use) Monitoring 1lResidential Type:'.•Slurry Li Pellets n9
Cl M unicipailPublic C Industrial/Commercial Ei Agricultural Water //6 gal. APR 1 9 ZQ23
:3 Recovery 0 Injection D Irrigation Other 7)ri. ° , i.!Ii:i
Irt :ii+i nt- :1
.I Other(list use) Type material
- Amount
3.WELL LOCATION:
COUNTY S• -ctYt IQ`'f QUADRANGiENAME
NEAREST TOWN: £ 4 Ili$Ckv_ 9. EXPLAIN METHOD OF EMPLACEMENT OF M/ATERIAL:
y7;,z F+ s"fh s i-(StreetlRoad Name,Number,Community.Subdivision,Lot No..Parcel.Zip Code) /um,t'
i,
TOPOGRAPHC I LAND SETTING:
:!Slope f'Valley Olaf i.L1 Ridge ;Other
(Check appropriate setting) 10. WELL DiAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth,depth and diameterof screens(if any)remaining
it
'�_� �1'S
LATITUDE _3�S°11 _ `7 "DYis OR 3x.xxxxxxxX}Q3D fn the well,gravel interval,intervals of casing perforations,and depths and
LONGITUDE
750-)9. / °DM5 OR 7x.XXxXxXXXt4D types of fill materials!sed
,
Latitudeliongitude source: I3PS Dlopographic map 11.. DATE WELL ABANDONED , 3
(location of well must be shown on a USGS topo map a,ldattached to
this form if not using GPS) I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the wall is located.Complete 4a: THIS RECORD S BEEN P13VIDED TO THE WELL OWNER.
(if a residential Well,skip 4a;complete 4b,welt owner information oily.) g3
��f 3 n_ _ . .
FACILITY iD#(if applicable) SIG RE�OF ERTiPIE ELL CONTRACTOR DATE
NAME OF FACILITY
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
Zip Code (The private welt owner must be an individual w�ersonallvabandonshslher resident!alwell
City or Town State in accordance with 15A NCAC 2C,0113.)
413,CONTACT PERSONMIELL OWNER: 7Tr/,/ L% 'f
NAME ,_'Da IA cI /. ci rj_3 G' 7 PRINTED IVANIE OF PERSON ABANDONING THE WELL
STREET ADDRESS /72 r, 544 Si O4kl3:cE be 1
1, Form GW-30
Submit a copy to the owner and the original to:Division of Water Quality-Information Processing, Rev.5/10
1617 Mail Service Center,Raleigh,NC 27699-1817,Phone:[phone]

WELL ABANDONMENT RECORD For internal Use ONLY: •
This form can be used for single or multiple wells -
1.Well Contractor information: WELL ABANDONMENT DETAILS ,
John W. Huneycutt 7a.Numberofwellsbeingabandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
constr ction ahandotmrens,you can submit one form.
2465-A 367.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Granular
2.Well Construction Permit#: 38131.0-2
List all applicable well permits(.e.County,State,Variance,Injection etc.)if known 7d.Amount of disinfectant used: 1/2 l b.
3.Well use(check well use):. _
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipallPublic 0 Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) El Concrete Grout El Drill Cuttings
❑irrigation ❑Specialty Grout El Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: If.For each material selected above,provide amount of materials used V' 'y;�;
DAquifer Recharge ❑GroundwaterRemediation 500 lbs. - Bentonite Slurry ,Y 1,.., "-`"'i.-. si '1"""J`"-r
❑Aquifer Storage and Recovery ❑Salinity Barrier 150 lbs. -Bentonite Chips _ APR 1 9 2023
❑Aquifer Test 0 Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment progedurei; ,3t1 P r c>7, g I.)0
❑Geothermal(Closed Loop) ❑Tracer t-u#''i2, ?
Well was pumped with bentonite slurry fromtottom
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
to 3' below surface through a 1"tremie pipe extending
4.Datewell(s)abandoned: 9/16/22 down into well. Remaining portion gravity filled with
5a.Well location: bentonite chips. .
Ben Chewning
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
178 Nicks Rd, Norwood 28128 coin, 6{9. YY 9/25/22
Physical Address,City,and Zip Signa,ge of Certified Well Contractor or ell Owner Date
Stanly 3751 By signing this form,,1 hereby cerl5 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:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)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
Ga.Well iD# abandonment to the following:
Division of Water Resources,information Processing Unit,
6b.Total well depth: 260 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Injection 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
6c.Borehole diameter: 6 (in.) abandonment to the following:
surface: 15 (ft) Division of Water Resources,Underground Injection Control Program,
6d.Water level below
ground 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
6f.inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known):- (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013