Iredell_Well Abandonment_20230825 (8)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONINIEN'T DETAILS
rr
Adam Wilcox 7a.For Gcoprobe/DPT or Closed-LoopGeothermal Wells having the same
Well CoutractorName(or well owner personally abandoning well on hisPoer property) well construction/depth,only 1 GW-30 is needed, Indicate TOTAL NUMBER of
4396—C wells abandoned: �
NC Well Contractor Certificnlion Number 7b.Approximate volnmc of water rei la,ning ill well(s): (gal.)
Yadkin FOR WATER SUPPLY WILLS ONLY:
Company Nome
7c.'1'ype of disinfectant used:
2.Well Construction Permit 0:
List all applicable well construction pen,ilis(i.e.UIC,Countyt Slate,I'arlance,ele.)fkno n
7t1.Amount of disinfectant used:
3.Well use(chedcwcll use): ,
Walter Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) G Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: 19 Bentonite Slurry ❑Other(explain under 7g)
Mmonitoring ❑Recovery
Injection Well: 7f,For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundRdter Remediation
I
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control❑Geothermal(Closed Loop) ❑Tracer �,
7g.Provide at brief description of the:tbandonnien(procedure:
The well was filled tq the top with a
❑Geothermal(Healing/Cooling Return) ❑Other(explain under 7g)
,� iV-7entonite and concrete grout slurry. A tremie pipe
4.Datewell(s)abaiidonedt 4/24/2023 was utilized to assure proper application of
51.Nell location: AUG 2 5'2023 the slurry.
Cain, Anne E N&woticrl tPf:!Ca"r4 Ufa
Facility/Owner Namc Facility IDN(i tYI 8.Certification:/
5066 Harmony Highway, Hamptonville, NC 27020 A e
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Irendell 4884111953
By signing this form, 1 hereby ceritr 'that the trell(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NC11C 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 degreeshninutes/seconds or deciurai degrees-
(if well field,one Intllong is sufficient) 9.Site dingrain or additional well details:
36.050572 N -•80.755154 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also all;ch additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBIMITTAL INSTRUCTIONS
Attadnrell constrricrion records)ifarailable.l or nurlNple Ajection ornan-m•aler supp!}melts
ONLY wnh the scone cousrrucilaii'abandoruue,rr,yai can submit one form.
10a. ForAll Wells: Submit this form within 30 days of completion of well
6a.Well IDH:AS•-10 abandonment to the following:
Division of Water Resource's,Information Processing Unit,
61a.Tolal well depi l: 60 (ft.) 1617 ir•Iail Serviec Ccnlpr,Raleigh,NC 27699-1617
101).For Iniection Wells: in addition to sending the fora to the address in 10a
6c.Borehole diameter:
$.25 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: �
i„
6d.Water level below ground surface: U nknown (ft) Division of Water Resources,Underground Injection Control Prograul,
1636 A4ail Service Center,Raleigh,NC 27699-1636
NA 10c.For NntcrSupply&Irriectiou MVells: In addition to sending the form to the
6c.Outer casing length(if known): (ft.) address(es)above,also submit one copy orthis forum within 30 days of completion
of well abandonment to the county health department of the county where
611 Inner casing/tubing length(if lmown): Unknown(ft.) abandoned.
6g.Screen length(if known): U n known (ft.)
l :
Fonn OW-30 North Carolina Department of Environmental Quality-Division of Water Resources 6 Revised 2-22-2016