Cabarrus_Well Abandonment_20230818 (14)

For Internal Use oriiY WELL ABANDONMENT RECORD..s .
1.Well Contractor Information: WELL ABANDONMENT.DETAILS
Billy Joe Payne Jr 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 his needed. Indicate TOTAL NUMBER of
3542-8 abandoned
:
d:
,
7b.A roximate volume of water remainiu .iu wells al
NC Well Contractor Certification Number PP g O. 6 (gal.)
Excel-SRP Environmental... FOR WATER SUPPLY WELLS ONLY:
�--�
p y 16• hlorinatiori-Ca(OCI)2
Coin an Name
4c:Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits O.e:UIC,County,State, ariance,.etc. :i known 3-oZ .
3.Well use(check well use): ir.;crn',:. _il t'!SG :
7d Amount of disinfectant used:
..
Water Supply Well:- 7e.Sealing materials used(check all that apply):
❑Agricultural:,..- OMunicipal/Public a Neat Cement Grout- a Bentonite Chips or Pellets
❑Geothermal;(Heating/Cooling Supply): :❑Residential Water Supply(;ingle) ❑ Sand Cement:Grout, q Dry.Clay
Dlndustrial/Commercial .. :.. ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑irrigation a Specialty Grout ❑ Gravel-.
Non-Water Supply Well: ❑Bentonite Slurry O Other(explain under 7g) -
eMonitoring: ❑Recovery
In"ection Well: 7f.For each material�' selected above,provide amount of materials used:
El Aquifer Recharge ❑GroundwaterRemediation :Neat Cement-104b.. Bento.nite-18-lb
El Aquifer Storage_and Recovery DSalinity Barrier
Flowable
❑Aquifer Test ❑Stormwater Drainage.
Fill:- lb-lb
OExperimental Technology .: ❑Subsidence Control
e a brief es abandonment
❑Geothermal(Closed Loop): ❑Tracer: _ -:,
7g.:Provide br' f description of the procedure:
Dropped Calcium-Hypochoritetablet into well casing and
[]Geothermal(14eating/Cooling Return) .. :D.Other(explain under 7g). :....
filled casing with-Bentonite pellets and:poured flowable fill.cement-.
'25-2023 7
4.Date well(s)abandoned: until approx.2-tbgl 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 00311 00-070000007582
Facility/Owner Name Facility ID#applicable) 8.Certification:
24 Church Street NE -�:-C��c _10_
8 2023
Physical Address,City,and Zip Sign ure of Cc"rtif Well C tractor 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 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 diagram or additional well details:
35.4121770 N - N -80.580737' 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 cons}ruction record(s)ifavailable..For multiple injection or non-watersupply wells
ONLY with 7hesame construction/abandonnieni,you can submit oneform.'' 10a. For All Wells: Submit this .form within 30 days of completion of well :.
6a.Well ID#:
M W—g: abandonment to the following:
D f W Division of Resource's-Information Processing Unit,
—26 ,.:1617 Mail Service Center,Raleigh-,-NC 27699-1617
66.Tatalwell depth: Me)
10b.For Imection Wells: -Iri.addition to sending the formto 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:
.I
6 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: ht_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): unk (ft) abandoned.
6g.Screen length(if known): 15 (ft.)
..: Form GW-30 North Carolina Department of Environmental.Quality-Division of Water Resources Revised 2-22-2016 .. .: .