Cabarrus_Well Abandonment_20230818 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT.DETAILS 1
_.
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 is'needed. Indicate TOTAL NUMBER of
3542-8 wells.abandoned:
NC Well Contractoi'Certification Number 7b.Approximate volume of water remaining in well(s):'2'1 (gal.)
Excel=SRP Environment• aI FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used;
2.Well Construction Permit#:
List all applicable well construction permits(i.e. WC,County,State,Variance,.etc.):iflmoivn 3-OZ'.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:. _ 7e.Sealing materials used.(ch_eck all that apply):
❑Agricultural; .- ElMunicipaVPublic a Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply), ❑Residential Water Supply(single) ❑ Sand Cement Grout. O Dry Clay
❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation C Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry = ❑ Other(explain under 7g)
GMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation . .Neat Cement—.1:0-lb. Bentonite-17-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
Flowable
❑Aquifer Test ❑Stormwater Drainage
Fill -lb
❑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) 00ther(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 0031.1 00-0-000.0007582
Facility/Owner Name •. Facility ID#(if pplicable) 8.Certifrca'on: �� r
24 Church Street NE �Iste� 10-2023
Physical Address,City,and Zip Si ture of CertiP60 Well eontractor or carer Q- qO23 Date
CABARRUS 28025. 56209806290000 v L
By signing this form, I hereb F tjjy--tthat t e well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC C.OI 0 � 071dllyC�n?Itzrction Standards
and that a copy of this record has been P110 R,well owner.
5b.Latitude and longitude in degrees/minutes?seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 9.Site diagram or additional well details:
35.4121770 N N -80.580737ow . 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-water supply.wells
ONLY with the same construction/abandonment,you can submit one forma
I�A`n' 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#• ' V V—1 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Totalwell depth:
"'22 (ft:) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: hi addition to sending the forzn.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:
'"9 6d.Water level below groun surface (ft.) Division of Water Resources,Underground Injection Control Program,
d
1636 Mail Service Center,Raleigh,NC 27699+1636
6e.Outer casing length(if known): (ft.) 10c.For Water Suaoly&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
6f.Inner casing/tubing length,(if known): u n k (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental.Quality-Division of Water Resources .. Revised 2-22-2016