Cabarrus_Well Abandonment_20230818 (8)

WELL ABANDONMENT RECORD..: For Internal Use ONLY:
1.'Well Contractor Information: WELL ABANDONMENTDETAILS
Bill Joe Payne Jr.y y7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning wcll.on his/her property) well construction/depth,only 1 GW-30,is needed. Indicate TOTAL NUMBER of
3542—B wells abandoned: CC
NC Well Contractor Certification Number 7b.Approximate.volume of Water remaining in well(s):. .5 {gp.
al.)
EXCeI'SRP EnVlrOnm • �a'I FOR WATER:SUPPLY WELLS ONLY:
: :
Company P y Name t Chlorination-Ca
AUGG 1 Q 2023 7c:Type of disinfectant used:
2.Well Construction Permit#: 1 U
List all applicable ivell construction permits J,e U AC C a 'a tc�e�rt� Jknown 3—OZ .
�i1iOt 7d.Amount of:disinfectant used:
J.Well use(check well use):
Water Supply Well: 7e..;Sealing materials used.(check all that apply):
❑Agricultural;.,_:- OMunicipal/Public " S Neat Cement,GO 1 a Bentonite Chips or Pellets
❑Geothermal'.(Heating/Cooling Supply). :❑Residential Water Supply(single) ❑ Sand Cement Grout :❑ Dry':Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation :C Specialty Grout ❑ Gravel.
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring' ❑Recovery
Injection Well: 7f.For.each material selected above,provide amount of materials used:
.I
❑Aquifer Recharge ❑GroundwaterRemediation :Neat Cement-1:04b Bento:nite-24-lb
❑Aquifer Storage and Recovery El Salinity Barrier
El Aquifer Test ❑StormwaterDrainage' : FlOWable Flll.=55-lb
❑Experimental Technology=.' ❑Subsidence Control
: 7g.Provide a brief description of the abandonment procedure:'
❑Geothermat(dosed 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 approx.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 00-07000.0007:582
Facility/Owner Name FacilitylD#(if applicable) 8.Certification:
24:Church Street NE C6ricac�. 8-10=2023
Physical Address,City,and Zip Si ature of Ce to Wel 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 1 SA NCAC WC.0100 or 2C.0200 Well Cbn'strirction Standards
and that a copy of this.'record has been provided to the well owner.
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient)
9.Site diagram or additional well details: . . ..
35.412177° N . . N -80.580737° W mYou may use the back of this page to provide additional well site details or well
abandonment details. You ay also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED : SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-walerstipply.wells
ONLY ivith'the same construction/abandonment,you can submit one font
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,.
'43 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total Well depth: A)
10b:For Iniection Wells: In:ad'dition to sending the form to the address in 10a
6c.Borehole diameter: 2 (in.) above,also submit one copy of this form 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&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
6f,Inner casing/tubingleng'th;(if known): u n K (ft.) abandoned.
6g.Screen length(if known): 2
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016