Randolph_Well Abandonment_20230724

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
J. Michael Venable 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 I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: '
NCWC-2079-A 1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 870 (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H ochlorite
7c.1'ype of disinfectant used: YP
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknou'n 27 Oz
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 Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) NResidential Water Supply(single) ❑ Sand Cement Grout N Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation well mix-4.5 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
QAquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer CHLORINATED; DEWATERED VIA TREMIE
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
PIPE; FILLED WITH WELL MIX TO SURFACE.
4.Date well(s)abandoned, 6130/23 ; ]]��'°°��
G 6'—i
5a.Well location: I I l l . A ?023
TOYOTA BATTERY MFG.
Facility/Owner Name FactlityID#(if applicable) 8.Certification: IrraeCl i7.�' rr�Lltir
4933 HOOTS HOLLOW RD., LIBERTY, NC ��'" '
Q. 1/2>{2�.�� 7/7/23
Physical Address,City,and Zip gnature of Certified Well Contractor or Well Owner Date
RANDOLPH By signing this forte, 1 hereby certify that the nvell(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.
(if tvr)16e1d,one lnt/longis sufficient) 9.Site diagram or additional well details:
35.884474 N -79.623153 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 DFTAII 4 OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well consiniction record(s)ttrarailable. For multiple h jection ornonavatersupply wells
ONLY with the some constructiontabandotunem,you can submit one fibrin.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 620 (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: 6 (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: 40 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft) 10c.For Water Supply&Iniection 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
6&Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department ofEmironmental Quality-Division of Water Resources Revised 2-22-2016