Stanly_Well Abandonment_20230807

WELL ABANDONMENT RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. Huneycutt 7a.Number of wells being abandoned: 1
Well Connector Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply ivells ONLY with the same
constructionlabandonment,you can submit one form.
2465-A 157.5
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Granular
2.Well Construction Permit#1: 370248-2
List all applicable well permits(.e.County,State,Variance,Injection,etc.)ifkninvn 7d.Amount of disinfectant used: 1/2 lb.
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 11�is�'O
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay -k �C 0'.
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttirj�gs -��11Y�lc <1 f
r
❑hri ation ❑Specialty Grout ElGravel .$ & S>A' �
Non-Water Supply Well: RI Bentonite Slurry ❑Other(explain and rqg)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials [
❑Aquifer Recharge ❑GroundwaterRemediation 300 Ibs- Bentonite Slurry
❑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 Well was pumped with bentonite slurry through a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
1"tremie pipe extending down into well.
4.Date well(s)abandoned: 10/28/22
5a.Well location:
Alan Boring Jr.
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
40654 Old Salisbury Rd, New London 28127gt-� 6t) y</z, � 11/15/22
Physical Address,City,and Zip Si a of Certified Well Contractor e0 Owner Date
Stanly 13851 By signing this form, 1 hereby certtfy that the ivell(s)was(1vere)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 owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach ivell construction record(s)if available. For multiple injection or non-water supply
ivells ONLY with the same construction/abmrdonmeni,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well IDH• abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth:
135 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 6 (in.) abandomnent to the following:
6d.Water level below ground surface: 30 (It.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.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
6E Inner casing/tubing length(if known): (ft) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013