Cabarrus_Well Abandonment_20230818 (9)

WELL ABANDONMENT RECORD-.: For Internal Use.0 LY
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy JOe.Payne Jr 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 ismeeded. hidicate TOTAL NUMBER of
wells.abandoned:
a d:
3542—B
NC Well Contractor Certification Number 7b.Approximate.volume of water remaining in well(s):.1
6
Excel:SRP Environmental FOR WATER SUPPLY WELLS ONLY:.
Company Name
7c:Type of disinfectant used Chlorination-Ca(OCI)2
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC"Cow SNe jagcenelt :j[ oivn _
. S r. m �i//Ries•gV] .Amount of disinfectant used:
3.Well use(check Well use): OZ
Water Supply Well: ,': _ 7e.Sealing materials used(check all that apply):
AUG 1 8 ZR3
❑Agricultural:.. :- OMunicipal/Public .. a Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal_(Heating/Cooling Supply) 1{ $osldi u faT4 6fkF uSup1 $") Cl Sand Cement Grout. :❑ Dry:Clay
3,
OIndustrial/Commercial ❑Residen f�t r upply(shared) ❑ Concrete Grout ❑ Drill Cuttings . ..
❑Irrigation a Specialty Grout E.I.Gravel. . .
Non-Water Supply Well: ❑ Bentonite Slurry - ❑ Other(explain under 7g)
Rmonitoring: ❑Recovery
:Injection Well: 7f For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-1,0-1b. Berltohite723-lb
❑Aquifer Storage and Recovery 0Salinity Barrier
Flowable
❑Aquifer Test ❑Stormwater Drainage
Fill -lb
❑Experimental Technology ❑Subsi den ce Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop)_ ❑Tracer.
Dropped Calcium Hyp ochorite tablet-into well casing and
❑Geothermal(Heating/Cooling Return) .. :❑Other(explain under 7g). :.
filled casing with-Bentonite e..l:lets.and: oured flow able fll cem ent
4.-Date well(s)abandoned:?-25-2023 " until approx.2-fbgl and poured neat cement inside casing to near the
sa.well location:. TOC and placed.the lid on the manhole for the monitoring well..
(Former) Servco 00311. . . 00-0-000.0007582
Facility/Owner Name S.Certi
Facility ID#(if applicable) fyation:
24:Church Street NE
1 t : C� IfcQ: 8-10=2023
Physical Address,City,and Zip Aignature of C _ified We Contractor or Well Owner Date
CABARRUS 28025- 56209806290000 -
By signing this form, 1 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 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 lat/long is sufficient) ,n.' 9.Site diagram or additional well details:
35.412027° N : N -80.580810° V V 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 WELL(S)BEING ABANDONED :. SUBMITTAL-INSTRUCTIONS
Attach well construction record(s)ifavailable.:Formultiple injection or non-watersnpply wells
ONLY with the same construction/abandoninent,you can submit oneform.'
I►t1`/t, 10a.'For All Wells: Submit,this form within 30 days of completion of well
6a.Well ID#: 'V'V'V—2' abandonment to the following::
sion of Water Resources Information Processing ,..Divi , g Unit
"44 1617 Mail Service Center,Raleigh;NC 27699-1617 -
6b.Total well depth: (ft.) .
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter- 2 (in:) above, also.submit one copy of this;form within 30 days7 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 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
6E 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 - .