Iredell_Well Abandonment_20230626 (2)

WELL ABANDONMENT RECORD nWELL
se O1.Well Contractor. nformation: NDONMENT DETAILS
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(of well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
.t� wells abandoned:
O'er�`• � .. �
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): * (gal.)
YADKIN WELL COMPAN[Y,INC. . FOR WATER SUPPLY WELLS
�}ONLY: O
Company Name C.LA `70 -G Y- 7c.Type of disinfectant used:
2.Well Construction Permit 2-0,7 q
List all.applicable well construction permits(i.e.UIC,County,Staid,Variance,etc)ifknown r
7d.Amount of disinfectant used: 0,2
3.Well use(check well use): `
Water Supply Well: 7e.Sealing materials'used.(check all that apply):
❑Agricultural OM,inicipal/Public Icat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) tike'sidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay e�
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout. ❑.Drill Cuttings
OIrri ation_ I C�_S.pecia v Grout. _____-________�❑ Gravel _ _ .___
No'ri-iVatei:.Suppij>V�ell'.L?i_ i" 'tAs i-Ti.: I i�i�r ,s,_3e C1sBbtlttiniteSlurt�r-1 ❑ Other(explain under7g)
❑Monitoring ❑Recovery -
Injection Well: 7L--For-each-material-selected-above,-provide-amou .of-rttateriails-used:j1 C.-If r.....i i.!ic:rnt:aie!n: `T:;i.i.:A,:.-`,';!!fl\�f ^T I)El':1.fI S- ?:.., / ,, •
❑Agtufer echarge ❑Grotindwater Remediation. - - �+
' •
❑A uifer St.ra a and Recovery:- - .;'OS'alini 'Barriers';t•n;hrrnla[�S', ;} ';.: ,.
❑r4quifer'Test`. ~❑SCormwaterDrainage - „! (.:':d t: .rrr sc,J. i;,ti':a:rJ I�.IV.,,� Ll'23..
❑Experimental Technology ❑Subsidence Control
--•-• 7 Provide a brief description of the abandonmdrrlit3Poeediwe� ��ef
rmaioinr.:n,. i +
❑Geotltermal.(Closed'Lo,op.) ❑Tracer tn;,:n:Itirat^. ''.us1,z a? r r. t:•; i_
17 eothermat(IJeating/Coolin Rerun),;`r.gOttter(ex lain under 7 ) T�'� h` e-�--•Gam.:+
.,
•: `f`��-acdc� �rw ! /'hC /w. t,u��i �. -� Vf'4-a✓.�t�
4.Date well(s)abandoned: 2_3 ,.: ;t r.•,euv: :.rr -------- --_�- _.._-_._ _
5a}:Well.location:h I
+ l i._. � '"n 8'il; :f:+'c�rr'Jtta rd��71"N�• uj e/! 4 6E dAk
!._'d"cilirylC3j-gi'-'Ngfi---;-----'"- ""' " '-" 'FacilitylDfl(ifapplicabrd)--'-- �•Certlfic 1 n:
r k
/:�hIL:H -/ Gr1.f�eyG�li�.r'I'►Vl('l7y'e.SW►�i.L° , 1L-7�.� .. CR:.:?„ - _ ',,I.aH e .:i,�, ,,t..,
Physidai'Addre'ssGity,!atid'.Zip''it:r ; - c, :.. m::'':' G� I,,,. �'�
" ' '' �' Signal '' fCeriiiie 1 o ctor or Well Owner -'r Date
1 s;:'I'l�: .,�".:;:!t'!tt::::�.'.":i•`: ::;II'i::i! �� !.;�!•:rCtU l.'i,li is �1 irnil!,ieil tl,CS �.
si nin this fq.r7n, 1 hereby certify that the wells) was(were)abandoned in
�areFl:Idenki6cationNn_(PIN)___. Qcc'o1, nc'e-iviOi"15ANCACOIC:OIOOor2Cr0 Ob='WellConstnrctionStandards
_...es................._...:,..., a`>tdSthed.6tipy'df leis record has been provided[o-ithe ive%talVrierit's 1"i
5b.jLatitVdx and longitude in degrees/mingle!eaouds or decimal degrees:
i
(ifiv,¢II6e1d;;;gnel'at/IotgisssitTicierii)-`-----t---- - - gf Redrag4am:br-addi�iana]iweii'details.iar. u:io.n.!_i,�rna'.-1:ia{=t,:r;i.
t..... .:,. ,:
? i,,: L,,; Yoii may=u'si the back-of`.this`_page fo:.provide additional well site details or well 0R
N U . L),a'�''�� ( W '
abandonment detai!s..You may also attach additional_pages if necessary.
"1
CONSTRUCTION DETAILS OF WELI.(Si•BEIIVG.ABANDONED... Sl7
Attacts,vellconstnictionrecord(s)rfavailable. Fornitiltipleiijeciion'ornon-watersupplywells SUBMITTAL INSTRUCTIONS.;__:-._, __
ONLY with the saute.construction/abandonment,you can submit one form. --
nii t s. frail;within130ildays_coE,completion of well
Ga.Well ID#:-(�(ih/K N ?c1{ a and owiri9.-
a ' or:. els:•�Su h1 .fa
b onnient in
Division of Water Resources,Information Processing Unit,
6b.Total well depth: l'iil/ 1I9 tJ1's✓ (ft;) 1 1617_J14ai1 Service Center,Raleigh,Nt 2769Q f617- _- _
I 10 b For Intechon Well In_addjtLqXL1Q sepdmg rho)Qptn to the_address to IOa
6E.I3o're1iol'tainmeter: (in.), ,. above,also submit one copy of this form within 30 days of completion of well
abandonmentJc_tliefollo�ffi*:.'c'1 . -- .-- ..• - . . -. .- . _.
-'- "" ;i +Division'of!Water'l3esources,Under round Injection Control Program,G'd:FYaaer7ewel`below ground surface: (f�� " (ft.) J g ,
1636 Maii'Service Ceutcr,Raleigfi;NC 27699-1636
6e.Oii'terleasin ten th ifkuoNri : '"`" I0c;For•Water.Sunaly.&In ectior Wells:: . addition to sendi the form to the
�' .g ( ) ''(ft.) ) � Pg
addresses)above,also submit one copy of this form within 30 days of completion
11 b d .---_--•......._..--..--. ._ __-•- _----.--- .... - .w ..,,a an onin. upty !healt#1 partrp nt�ol',thct county where
.,, c
6f.Inner casing/tubiug:length(IPknotvii)'r'.' ' ':, . °"t(ft.) - .. „ eao i;r';`ri'•r':`'nrrr:.'„ .
o e ent:to..th de
- , abandoned-; ; , ; .•, _ -
- ..... —.._.._..... ..._. .._ - ._....... ...,•tlir.::i'• e:.i}i,'. ,,., :rci i:rr,t 1::: f_ ,s
.,..a•4�•' ?l i. .tic .. _, .:'L',i tlu+28ia -ih e,i ,. .io. .. .. .. ...',%!7•..�?i!r.t,J.i'•".i,!!i''^. _
6 .-Screen'len thfk ipown *
g. ,g ( ): ..(ft) `)� <(xi.• :i15Y1. '!Fi:itrli#t:,,,:,}i•!.Y.b."r^ , . .._...,,t>! • -: ..
Form GW-30. . North Carolina Department.of Environmental Quality-Division of Water Reso trees Revised 2-22-2016