Rowan_Well Abandonment_20230602 (3)

WELL ABANDONMENT RECORD For Internal Use 0-NLY:
.This font earl be used for single or multiple Wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
KENNY SARGENT 1
7a.Number of wells.being abandoned.-
Well Contractor Name(or well owner personally abandoning well on his/her property) Far andliple injecliot or non-;rater supply, melts ONLY with the same
A - 4226
c'onsirtictioii abotutortateat,.you can stibnit one form.
,
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number ..
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Naine 7c.Type of disinfectant used:
2.Well Construction Permit#:
list all applicable mell coaslruction permits(i.e.County,State,Variance,etc.)ifknomn 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement ut ❑ Bentonite Chips or Pellets
❑Geothermal(Fleating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement rout;^ tip LT;Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout r ❑-Drill Cuttings
❑Irri ation ❑ Specialty Grout JUN V r 2023 ❑ Gravel.
Non-Water Supply Well: 0 Bentonite Slurry
❑ Other(explain under 7,o)
❑Monitoring ❑Recovery IR9�"' `:'^' '� �` i
7f.For each material selecfeiiatiocti, rovide amount of materials used: 'ln,jection Well: p
❑Aquifer Recharge ❑GrOnndwater Remediation 1:O.GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE HOLEPLUG
❑Geothermal(Heating/Cooling Return) ❑Other(explain under-7g) .
4.Date well(s)abandoned: 05/16/23
ia.Well location:
BUCK STEAM STATION
Facility/Owner Name Facility IDN(if applicable) 8•Certification:
1555 DUKEVILLE ROAD SALISBURY 28146 05/22/23
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
ROWAN By signing this form. I hereby certify that the ivell(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 ouiner.
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees.,
(if well field,onelat/long is sufficient) 9.Site diagram or additional well details:
350 42' 49.39" N 800 22' 06.13" \\ 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 consiruction record(s)if available. fbr multiple injeclion or non-water supply
melts ONLY midt the.sane conslruction'abmtrlonntent,you call suborn one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#:
PZ-21 abandonment to the following:
Division of Water Quality,information Processing Unit,
Gb.Total well depth: 24.0 (ft.) 1611 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
1.0 above,also submit one copy of this font within 30 days of completion of well
Gc.Borehole diameter:_ (in.) abandonment to the following:
i
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Sunoly& Iniection Wells: In addition to sending the form to
Gc.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
Where abandoned.
611 Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form G W-30 North Carolina Departinent of Environment and Natural Resources—Division of Water Quality Revised March 2013