Stanly_Well Abandonment_20230807 (4)

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 Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells `ONLY- with the same
consiructimr/abandonment,you can submit oneform
2465-A
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.Typeofdisinfectantused: Granular
2.Well Constriction Permit#i: 396308-1 /
List all applicable well permits(i.e.County,State,Irdriance,Injection,ela)ijlmown 1/2 lb.
Amount of disinfectant used:ii'
3.Well use(cheek well use):
7e:Sealin materials used,check all that apply):
Q���
Water SnPPh Well: g ( N
❑Agricultural ❑Municipal/Public O Neat Cement Grout ❑Bentonite Chips or Pellctsl�
❑Geothermal(Heating/Cooling Supply) OResidential Water SuPP1Y(single) ❑.Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑Drill Cuttings
❑Irri ation ❑;Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials.used;
❑Aquifer Recharge ❑GroundwaterRemediation 900 lbs. - Bentonite"Slurry'
❑Aquifer Storage and Recovery ❑Salinity Barrier
120 IbS. -Concrete Grout
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control 79.,Provide a brief description of the abandonment procedure:
❑G eothermal(Closed Loop) ❑Tracer Bentonite slurry was pumped from the bottom up
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
to"3' below.surface through a.1"tremie pipe extending
4.Date well(s)abandonea: 6/29/23 down into well. Concrete grout was gravity fed into
5a.Well location: well.frorrl a depth of 3' up,to.ground"surface.
GST Exempt Trust
Facility/Owner Name Facility ID#(if applicable)
8. 'fication:
24464D River Loop Rd, Albemarle 28001 7/12/23 X 0. A war,
Physical Address,City,'and Zip S106t.of Certified Well Contractor or Well Owner Date
Stanly 14162 By signing this form,I hereby certify that the well(s)was(tvere) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constniction 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 latllong 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable. For multiple injection or non-water supply
wells ONLY wide the same constructionlabandonment,you can submit one form. 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: 12 (fL) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in Ina
14 above,also submit one copy of this form within 30 days of completion of well
6c Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: N/A (It,) 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 Sunnly&Infection 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
6E Inner casingitubing length(if known): (pw) where abandoned.
i
i .
6g.Screen length(if known): (ft.)
Form OW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013