Randolph_Well Abandonment_20230505

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Corey D. Futral 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
4300-B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Catlin Engineers and Scientists_ FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: �"
2.Well Construction Permit#: NA MAY 0 5 2023
List all applicable well construction permit's(i.e.(11C,C'oway,State,Variance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use): r r?f
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 19 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry 19 Other(explain under 7g)
GMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 100lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage Concrete 12.5 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well abandoned in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
pellets to within 6 inches of surface and topped with
a.Date well(s)abandoned: 4/4/2023 concrete to existing grade.
5a.Well location:
NCDEQ-Routh's Gulf NA
Facility/Owner Name Facility ID#(if applicable) S.Certification: v.
3233 W.O.W Road, Randleman, NC 27317 4/27/2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph 7764767765
By signing this form, 1 hereby certify that the ivell(s).was (weir:) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 at-2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.799530 N -79.783018 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 cant traction records)ifavailable.Fortmdtiple injection or non-water supply wells
ONLY with the same eonsiructionlabamlonment,you can suhmit one fo•m.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (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: 8.25 (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: 45.83 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Sunuly&Injection 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
6G,Inner casing/tubing length(if known): 40 (ft) abandoned.
6g.Screen length(if known): 1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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