Sampson_Well Abandonment_20230706

1.Well Contractor Information: WELL ABANDONMENT DETAILS
Ronald G. Cannady '
7a.For Geoprobe/DPT or Closed-Loop Geothermal Walls 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
2126 A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s):
Cannady Brothers Well Drilling, Inc FOR WATER SUPPLY WELLS ONLY:
Company Name y`� �r y l lY✓'� (y y
7c.Type of disinfectant used:
2.Well Construction Permit#: r I �" ar D'r►(r)3 V
List all applicable well Construction permits(i e.UIC,Cotdajy St�e ajree,,gt .)5flolawn
7d.Amount of disinfectant used: tr-
3.Well use(check well use): /;• ZQ23
Water Supply Well: le.Sealing materials used(check all that apply):
❑Agricultural ❑Mnuni�jp)1UPnlilie �`'''r"?")L ❑Neat Cement Graut entonite Chips or Pellets
.: �
❑Geothermal(Heating/Cooling Supply) 0 ential WatFr Sup ply,(single) ❑Sand Cement Grout lay
❑lndustrial/Commercial ❑Residential Water Supply(shared) d Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7G For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwatef Remediation JC ILE S
❑Aquifer Storage and Recovery OSaihnity Barrier
❑Aquifer Test ❑StormwaterDrainage ''` rr' b ��-">17�a I�p --
❑Experimental Technology OSubsidence Control 7g•Provide'a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Trncer ._ .,p„ �� �� �� _n,,�-
❑Geothermal(Heating/Cooling Return ❑other lain under 7g) �.,elJ�� �X�t C� a
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4.Date well(s)abandoned: "' _` � ��, j P
ISa.Well.lacation �—a '�/ tj ex �c� et9�Y� u,.t✓�(J
J ro Ill &
Facility/Owner Name Facility ID#(if applicable) 8.Certification: �l�'l . ` L �� `' ►�
1.4 �5.3. , � R.R�l1s.. w --- .14 9r �'
Physical Address,City,and Zip Signature of Certified WcH Contmc or or Well Own& Date
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L 13y�sighing this form,I hereby certify that the wells) was(were)abandoned in
County t Parcel Identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to tire well owner.
56.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:
N '`�d -A ) 3(p 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 MAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.Formultiple injection ornon=water supply wells
ONLY with the saute construction/abandonment,you can submit one form. 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well Dom• abandonment to the following
0+ Division of Water Resources,Information Processing Unit,
6b.Total well depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. f ( above,also submit one copy of this,form within 30 days of completion of well
abandonment to the following:
6d.Water Ievel below ground surface: , `vv (ft.} , Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
yvof :-tea
6e:0oter casing length(if known): I✓ (ft.) lOc.For Water Saaoly&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
6f.Inner casing/tabing length(if known): Yl� (R,) abandoned
6g.Screen length(if known): 1 J —(fL) R -

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