Cabarrus_Well Abandonment_20230818

WELL ABANDONMENT RECORD For Internal Use ONiY:
:1.4ell Contractor Information: WELL ABANDONMENTIATAILS
Billy Joe Payne J r' 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
3542-B abandoned:wells an d:
NC Well Contractor Certification Number 7b.Approximate_volume of water remaining in well(s): 1' (gal.)
Excel-SRP Environmental = FOR WAT
ER SUPPLY WELLS ONLY;::
Company Name hlorinatioh-Ca(0Cl)2
7c:Type of disinfectant usedi C
2.Well Construction Permit#:List all applicable we!l construction permits e J1C'C untj Sta l et :ijknown 3-Oz
.,c c c 7d.Amount of disinfectant used:
3.Well use(check well use):
AU n 2
"Water Supply Well:. ru- 7e.:Sealing materials used,(check-all that apply):
[]Agricultural. ❑Mpnici 1f�Pub' tiR .:. a Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Suppl "❑ W tt�aWKrcr Supply(single) ❑ Sand Cement Grout, :❑Dry';Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings :. .
❑Irrigation a Specialty Grout ❑ Gravel. .
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
NMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-.10 4b. BentO,nite-23-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage FlOW86le Fill.-55-1b
DExperimental Technology ❑Subsidence Control
7g..Provide a brief description of the abandonment procedure:
[]Geothermal(Closed Loop): ❑Tracer.:
Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal.(Heating/Cooling Return) .. :❑.Other(explain under 7g).
filled casing with Bentonite pellets.and:poured flowable fill cement.
4.Date well(s)abandoned: 7-25-2023 until 6 prox.2-fbgl and poured neat cement inside casing to near the
5a.Well location: TOC and placed.the lid on the manhole for the monitoring well.
(Former) Servco 00311.. 00-0-000.0007582
Facility/Owner Name Facility ID# licable) 8.Certi Hon:
24-Church Street NE C� �� f 8-10-2023:;
Physical Address,City,and Zip Sig tore of UrOy Well ontractor or Well Owner Date
CABARRUS.28025 : 56209806290000 .
By:signing this form, I hereby certify that the well(s),was (were) abandoned in .
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Cbminiction 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:
(if well field,one lat/long is sufficient)
9.Site•diagram or additional well details:
35.4121770 N N -80.5807370 W 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 DETAILS OF WELLS)BEING ABANDONED . SUBMITTAL INSTRUCTIONS '
Attach well construction record(s)ifavailable..For multiple injection or non-water supply.wells
ONLY with the same construction/abandon»lent,you can submit one form.
1►/I'/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V'V V-1 abandonment to the following:
Divis
ion of Water Resources,Information Processing Unit,
6b.Total well depth: - (ft:) 1617 Mail Service Center,Raleigh;NC 27699-1617 .
lob.For Infection Wells: In addition to sending the forni:to'the address in 10a
6e.Borehole diameter: 2 (in:) above, also submit one copy of this Morin within 30 days of completion of well
abandonment to the following:
'"34 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC.276994636
6e.Outer casing length(if known): (ft.) 10c.For Water Suonly&Infection Wells: hi addition to sending the form to the
address(es)above;also submit one copy of this form within 30 days of completion
g of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): u n k (ft.) abandoned.
6g.Screen length(if known): 25
Form GW-30 North Carolina Department of Environmental:Quality-Division of Water Resources .. Revised 2-22-2016