Jackson_Well Abandonment_20230505 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Randy Brand 7a.For Geoprobe/DPT or Closed-I op Geothermal Wells 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
3029-A wells abandoned:
7b.Approximate volume of water remaining to wells. 1.14 al NC Well Contractor Certification Number PP g' O' (gal.)
Terry Environmental Services - NC FOR WATER SUPPLY WELLS ONLY:
Company Name . �-
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,Comity,Stale, Variance,etc.)ifknown MAY O ,
7d.Amount of disinfectant used: �
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): `>`Qr301- Ura
❑Agricultural ❑Municipal/Public a Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation -1.92 gallons of water
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage -0.24 Bags of Portland Cement
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Concrete well pad and well vault removed
1" Tremie pipe placed to bottom of'well
a.Date well(s)abandoned: 4/3/2023 Neat cement filled well from bottom to top
5a.Well location: A similar surface material finished at top
Hot Spot#1000 00-0-0000035727
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
551 East Main Street, Sylva, NC 28779 ,E 4/12/23
Physical Address,City,and Zip Signature ofCertifief Well Contractor or We 1 Owner Date
Jackson 7641-66-7355
By signing this form, 1 hereby certify 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
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 lat/long is sufficient) 9.Site diagram or additional well details:
35.37062 N -83.20463 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. Formultiple injection or non-water wells
ONLY with the sane construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 12.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (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: 5.00 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 2.0 (ft,) 10c.For Water Supply&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
N/A of well abandonment to the county' health department of the county where
6E Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): 10.0 (ft.)
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016