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Home My WebLink AboutIredell_Well Abandonment_20230825 WELL ABANDONMENT RECORD Far Internal Use ONLY: II 1.Well Contractor Information: WELL ABANDONMENT DETAILS' Adam Wilcox 7a.For GeoprobelDPT or Closed-Loop IGeothernnnl Wells;having the saute Well ContractorNnme(or well owner personally abandoning well oilhisfher property) well constnictiouldepth,only I GW-30'is needed. Indicate TOTAL NUMBER of 4396-C wells abandoned: NC Well ConlmctorCertificalionNumber 7b.Approximate volame of water rerltnining in Ivell(s); (gat.) Yadkin FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used; 2.Well Construction Pcr•rttit N: h List all applicable well construction pernfts(i.e.UIC,Couury,State,Variance,eta)(f known 7d,Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e,Scaling materials used(check all thnt apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Benlonite Chips or Pellets El Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) 9 Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑Gravel Non-Water Supply Well; a Bentonite Slurry ❑ Other(explain under 7g) INMonitoring ❑Recovery Injection Well 7f.For each material selected above,provide amlottat of materials used: ❑Aquifer Recharge ❑Ground«ater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier f ❑Aquifer Test ❑Stormnvater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descriptiou of the;labmtdonntent procedure: ❑Geothermal(Closed Loop) !]Tracer []Geothermal(I•Ieating/CoolingReturn) ❑Other(explain under 7g) The well was filled to the top with a r -�-� entonite and concrete brout slurry. A tremie pipe a.Date well(s)abandoned. 4/24/2023 SCE I tl) was utilized to assure proper application of SR.Well location: AUG 2 5"2023 the slurry, Cain, Anne E NA __ tnCeawa Wqc Facility/OwnerNatne FaciitylDH(i � 'F S.Cerdfication: r /� 5066 Harmony Highway, Hamptonville, NC 27020 A4_ J 7'�v17" ;,do?" Physical Address,City,and 7ip Signature of Certified Well Contractor or Well Owner Date Irendell 4884111953 By signing this form,I hereby certhi that the well(s) was(were)abandoned ill County Parcel Identification No.(PIN) accordance frith 15,1 NCAC 02C.0100 or 2C.0200 TVell Construction Standards and that a copy of this record has beer provided to the well owner. 5b.Latitude and longitude in degrees/ntimites/seconds ordecbnal degrees: (ifwell field,one fat/long is sufficient) 9.Site diagram or additional well details: 36.050572 N -80.755154 " You may use the back of this page to,;provide additional«v11 site details or well abandonment details. You may also attach additional pages if necessary. CONS'rRUCfION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTROCTIO+N`S .lwrack+reNconslrucHvnrecord(s)lfaraflable,!brutalriplehject(ana•nat-tralersupply>ive!!s � ONI Y with the same constrrtctionlubartdotnnrni,you can subunit one form. 10a, For All Wells: Submit this form within 30 days of completion of well 6a.Well IDR:AS-1 abandonment to the following: i I: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 60 1617 Mail Service Center,Raleigh,NC 27699-1617 10b, Feu-lniectiou Wells: In addition to sending the form to the address in 10a 6e.Borehole diameter-: 8.25 (in) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: Unknown Division of Water Resources,Ual ct,ground Injecdom Control Program, Gtl.Witter lewd below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636 Gc.Outer casing length(if known):n): NA —(ft.) 10c.ForWater Supply s 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/titbhrg length(if known): U n known(ft.) abandoned, 1 i 6g.Screcn Icngtin(if lunotvn): Unknown (ft.} I Fonn OW-30 North Carolina Department of Environmental Quality-Division of Water Resources I' Itciiscd 2-22-2016 f � i WELL ABANDONMENT RECORD For Internal Use ONLY: � I 1,Well Contractor Information: 1VELL ABANDONMENT DETAILSI I Adam Wilcox 7n.For Geoprobv/DPT or Closed-Loop Geothermal Wells having the same Well ContmctorNanto(orwcll ownerperso+ally abandoning well on his/her property) well constntotiol/depth,only I GWAn is needed. Indicate TOTAL NUMBER of 4396-C wells abandoned: I I NC Well Contractor Certification Number 7b.Approximate volume of tvaler relitainimg in well(s): (gal.) Yadkin FOR WATER SUPPLY WELLS ONLY: Company Namc 7e.Type of disinfectant used: 2.Well Cotstructiot Permit#: j JAI all applicable it-ell conslrrrcdou peratns(i.e.VIC,C•oano%Stare,irariance,etc.)ff lo+mrn 7d.Amount of disinfectant used: I 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(cheelc all(hill apply): ❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout ❑ Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout 1 ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑ Drill Cuttings ❑irri ation ❑ Specialty Grout ❑Gravel Not-Water Supply Well: s Bentonite Slurry ❑Other(explain tinder 7g) b Monitoring ❑Recovery Injection Well: 7C For each material selected above,provide 211101111(Of Materials used: ❑Aquifer Recharge .❑Groundwater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Tes( ❑Slortmvater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of theMandouuent procedure: ❑Geothermal(Closed Loop) ❑•tracer The well was filled to the top with a ❑Geothermal(Heating/Cooling Return) []Other(explain under 7g) 4.1)ate well R �E=I tonite and concrete:grout slurry. A tremie pipe • (s) tbamloned: 4/24/2023 was utilized to assure proper application of 5a.Well location: AUG 2 5"202� Cain, Anne E NA 7+r the slurry. Ir>brt'�� Facility/Owner Name FacilitylDti(ifappl b .. 8,Cer/�ti.Fic/�allot: r- 5066 Harmony Highway, Hamptonville, NC 27020 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Irendeil 4884111953 By signing this form, I hereby cerlifyl that the svell(s) was(were)abandoned in County Parcel identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards and thal a copy of this record has been,provided to llte well owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one latilong is sufficient) 9.Site diagram or additional well details: 36.050572 N -80.755154 W You may use the back of this page toy provide additional well site details or well abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF R'ELL(S)BEING ABANDONED lintacin+•eelcarslrrrcllarrecolzl(sJifm'atiable. Fin'1NtrlllphtrJecllwlol•ltan-sralersuppiyu'elts SUBi14ITTALINSTRLJCTIONS OA`LYl+'lair the sane carslr++cliar�abanJontuenl,3'ort can subnrin are jornr. ' l0a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#:AS-2 abandonment to the following: I Division of Water Resources,Information Processing Unit, 6b.Total well depth: 60 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b. For Iuiectiou Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 8.25 (in,) above,also submit one copy of this form within 30 days of completion of well abandonment to the following: Unknown Division of Witter Resources,Un lcrgroand Injection Control Program, 6d.Water level below ground surfacle�:r (ft.) 1636 Mall Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 'V A (ft) 10c.For Wafer Slronly&lt!eetion 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 6C Inner easing/tttbing length(i£known): Unknown(ft.) abandoned. i i 6g.Screen length(if known): U n known (ft.) Fonn GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 t I.