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Home My WebLink AboutCabarrus_Well Abandonment_20230818 (12) WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT.DETAILS Billy Jae'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 GW730!is needed. Indicate TOTAL NUMBER of wells ab ndone d:3542-6 I 13 NC Well Contractor Certification Number 7b.'Approximate.volume of water remafiningigwell(s)f (gal:) Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:: Company Name. { ' � . 7e.Type of disinfectant used: Chlorinatlon-Ca(OCl)2 2.Well Construction Permit#: List all applicable ivell construction permits(i.er UIC,County k e VaJia ff N)2fPo,- ctant used: 3—oz.- 7d.Amount of:disinfe 3'Well use(check well use): rT.2►[1:n i'�CL`.�4�GP liit� Water Supply Well: p�j '}jil 7e.Sealing materials used.(check all that apply): ❑Agricultural: _ OMunicipal/Public C 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 N 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: 4, ❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-1.0-lb, Bent6nite-25-lb El Aquifer Storage and Recovery El Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage F�OWab�e FIll=50-fib ❑Experimental 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. C 4'.'Date wells abandoned: 7-25-2023 O 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 0031.1:. 00-0-0000007582 Facility/Owner Name Facility ID#applicable) 8.Certific�n: 24 Church Street NE �cdf ... _ 8-10-2023 . r� Physical Address,City,and Zip Sign ure of Certified ell 6ontVtor or Well Owrier 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 Constritction 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: 35.412177° N .. N -80.580737'. 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-ivater supply,wells ONLY with the saute constnrction/abandonnient,you can submit one form. 1►A`/t' G 10a. For All Wells: Submit this form within 30 days of completion of well :6a.Well ID#• 'V'V V—V abandonment to the following: Divis ion of Water Resources;Information Processing Unit, . "'40 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Totalwell depth: (fts) l0li.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: —32 _ (ft.) 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 Supply&Injection 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 Of known): u n k (ft.) abandoned. 6g.Screen length(if known): 20 (tt.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 . .r. WELL ABANDONMENT RECORD-- For Internal Use OlVI l 1.Well Contractor Information: WELL ABANDONMENT.DETAILS Bill Joe-Pa ne Jr I Y -.. y 7a.For Geoprobe/DPT or Closed-Loop'Geothermal Wells having the same Well ContractorName(or well owner personally abandoning well on his/her property) well construction depth,only 1 GW-30 islneeded. Indicate TOTAL NUMBER of 3542-B abandoned:wells. 7b A roximate volume of water remainin m well(s): 2' al NC Well Contractor Certification Number " ' PP remaining in g. Excel-SRP Environmental FOR WATERSUPPLY WELLS ONLY: Company Name - t 7c.Type ofdisinfectant used: Chlorination Ca(OCI)2 2.Well'Construction Permit I. B./ List all applicable well construction permits ri.e.UIC, ouniy7Y7me, arrance,- tc. i own 3-oz .AUG �..8 2023 _. ecan _. 7d Amount of.disinf t t used: S. Well use(check well use): . Water Supply Well: n�, le..:Sealing materials used.(check all that apply): voim 1 . ❑Agricultural: :"; O1Vlunicipal�i ,3v� a Neat Cement Grout a Bentonite Chips or Pellets ❑Geothermal.(Heating/Cooling Supply). :❑Residential Water Supply(single) ❑ Sand Cemenf Grout ❑Dry:Clay ❑Industrial/Commercial :. .. ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings :. ❑Irrigation :e Specialty Grout ❑ Gravel. .:. . Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) SMonitoring: ❑Recovery :Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-8.5-lb Bent0nite-23-lb ❑Aquifer Storage and Recovery ❑Salinity Barrier - - ❑Aquifer Test ❑StormwaterDrainage_ FlOWa�Jle FI��.=45-�b :ElExperimental Technology: _- ❑Subsidence Control : - -_ _ e a brief description abandonment ❑Geothermal(Closed Loop): ❑Tracer:: 7g.:Provid b f d ription of the procedure:' Dropped Calcium Hypochorite tablet into well casing and ❑Geothermal(Heating/Cooling Reium) .. ❑.Other(explain under 7g), filled casing with'Bentonite pellets.and poured flowable fill ceinent- _. :4.Date well(s)abandoned: :?-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 monitoririg well.:. (Former) Servco 00311..: : 00-0-000.0007:582 Facility/Owner Name ': ,. : Facility ID#(K applicable) Certification:8. - 24.Church Street NE � 8-10-2023. Physical Address,City,and Zip Signa re o Certifed ell Con ctor 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 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: (if well field,one lat/long is sufficient) 9.Site diagrarmor additional well.details: 35.412177' N N -80.587370o 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 record(s)ifavailable.,For multiple injection or non-water supply wells _. . ONLY with the same construction/abandonment,you can submit one form. n A`A'' 16a. For All Wells: Submit this form within 30 days of completion of well V' :- 6a.Well ID#• ' V V-7' abandonment andonent to the following:. -37 D, sion of Water Resources;Information Processing Unit,_.: V,1617 Mail Service Center,.Rateigh,:NC 27699-1617 , ... . . 6.b..Total well depth: (fL) 10b:For Infection Wells: In.addition to sending the-forin 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: "-24 Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: :0t.) ..- 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): 20 Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 •.