Cabarrus_Well Abandonment_20230818 (10)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.DETAILS
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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-30ris needed. Indicate TOTAL NUMBER of
3542-8 abandoned:wells"
NC Well Contractor'Certification Number' C �°+, �.w. 7b:Approximate volume 6f water remaining in.well(s): 1.8 .
(gal.)
Excel--SRP Environmental AUG� � � FOR WATER SUPPLY WELLS ONLY:: ;
Company Name A 1 8 2023 7c.Type of disinfectant use& Chlorination-Ca(OCl)2 —
2.Well Construction Permit#:
List all applicable well construction permits(r.e.UIC, L a eT,,�gqr�A''"' rflno P 3-oz
tJPi �rv'. 7d.Amount of disinfectant used:
:3.Well use(check well use):
Water Supply Well:. ... 7e..Sealing materials used(check all that apply):
❑Agricultural; pMunicipaUPublic a Neat Cement Grout 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 e Specialty Grout ❑ Gravel,. :. . .
Non-Water Supply Well: ❑ Bentoni_te 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-1.3 .1b. Bentani'te-20-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage FlOWBble F1ll.=58-lb
El Experimental Technology ❑Subsidence Control
' , of the a an onme7g.:Provr e a brief description n t procedure:
❑Geothermal(Closed Loop) OTracer
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) SerycO 0031.1. 0070-000.0007582
'Facility/Owner Name Facility ID# tfapplicable) rhtcatio• S.Ce 'f
24.Church Street NE 8-10-2023;
Physical Address,City,and Zip Sign re of Certif Well Co ctor or Well Owner Date
-.CABARRUS 28025 56209806290000
By'signing this form, I Hereby certi+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:Iongitude in degrees/minutes/seconds or decimal degrees: . .. . .
(if well field,one lit/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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-watersupplyivells
- ONLY Wth'the same construction/abandonment,you can submit one forma
I►A,n` C 10a. For All Wells: Submit this form within 30 days of completion of well
:6a.Well ID#• 'V I V V—`� abandonment to the following:
Division of Water Resources;Information Processing Unit, .
(ft.)6b.Total well depth:
"'4.5 1617 Mail Service Center,Raleigh;NC 27699-1617
10b.For Infection 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 days.of completion of well
abandonment to the following:
6d.Water level below ground surface:
"'34 Division de of Water Resources,Unrground Injection Control Program,
(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
6f.Inner casing/tubing length(if known): u n k (ft) abandoned.
6g.Screen length(if known): 25
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016