Cabarrus_Well Abandonment_20230818 (6)

WELL ABANDONMENT RECORD For Internal Use,ONLY: d.
1.Well Contractor Information: WELL ABANDONMENT:DETAILS i .
i
Bill Joe Pa ne Jr
Y y 7a.For Geo robe/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-3�0 is needed. Indicate TOTAL NUMBER of
_ abandoned:
�+ ..
NC Well 3542on�ctot'Certification Number' 7b.wells
water rem 2 .6
w d: ,
imate volume of w remaining in well(s)i {gal:)
Excel-SRP Environmental FOR WATERSUPPLY WELLS ONLY:
: :
Company Name
-7c.Type of disinfectant used- Chlorination Ca.(OCI)2
2.Well Construction Permit#:
List all applicable ivell construction permits(i.e.UIC,County,State,Variance,etc.)if known 3_oZ"
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well:. 7e.;Sealing materials us
ed.(check all that apply):-
❑Agricultural_-;-: ❑Municipal/Public C Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal:(Heating/Cooling Supply.) ❑Residential Water Supply(single) ❑ Sand Cement:Grout. ❑Dry Clay
OIndustriaUCommercial .. :.. OR
esidential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings ..
❑Irrigation a Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
mmomtoring; ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
,� l.,
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement-1:0-Ib Bentonite-l8-lb
❑Aquifer Storage.and Recovery 0Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage FlOWable F1��=28-fib
DExperimental 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) .. :OOther(explain under 7g). :.
G filled casing with Bentonite pellets and-poured flowable fill cement
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) Seryco 00311 00-0-000.0007582 Facility/Owner Name _ Facility ID#(i pplicable) 8.Certifica'on: 1 �'�vN
"
Church Street NE Cb�� / AUGI 8 20 10-2023 _.
Physical Address,City,and Zip Sigglaiureof Cert' ed Nell ontractor or Well Owner Date
CABARRUS 28025 . 56209806290000 a h Irfar�t° :iL,1 arc t
y-signing this form, I hereby certify that thDV} M (w re a andoned 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/minuteslseconds 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
Attach well construction record(s)ifavailable..For multiple injection or non-water supply wells SUBMITTAL INSTRUCTIONS
ONLY with the same constructionlabandonnient,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M V V `t' abandonment to the following:
sion of Water Resources;Informa
6b,Total Well depth: tion Processing Unit,
"25
(ft:) DiVi.1617 Mail Service Center,R,aleigh,NC 27699-1617
10
0.For Iniection 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:
6...Water level below ground surface: 8'5: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC.276994636
6e.Outer casing length(if known): (ft.) 10c.For Water Suualy&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.(1 U n k abandoned.
if known): (ft.)
6g.Screen length(if known): 15
I i
Form GW-30 North Carolina Department of Environmental.Quality-Division of Water Resources .. Revised 2-22-2016 .