Iredell_Well Abandonment_20230825 (10)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
� I
1.Well Contractor•Information: WELL ABANDONMENT DETr11LSII
Adam Wilcox 7a.Fill,Geoprobc/DPTor Closed-Lo pLothernialWellshavingthesame
Well Contractor Nanne(or well owner personally abandoning well on histlter property) well construction/depth,only i GW-30�is needed. Indicate TOTAL NUMBER of
4396—C wells abandoned: I 1
NC Well Contractor Certi6calion Number 7b.Approximate volume of water remaining Ill well(s): (gal.)
1.
Yadkin FOR 1YATER SUPPLY WELLS ONLY:
Company Name i'
7c.Type of llisinfecfan!used:
2.Well Construclion Permit N:
List fill applicable aril cotsaucilon permits(i.e.UIC,County,State,irariauce,etc)ifknown
7d.Amoun(of disinfectant used:
3.Well use(cheek well use):
i
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neal Cement Grout ❑ Benionite Chips or Pellets
❑Geothermal(Ilealing/Cooling Supply) aResidential Water Supply(single) 17 Sand Cement Grout ❑ Dry Clay
111ndustrial/Commercial ❑Residential Water Supply(shared) I,Concrete Grout ❑ Drill Cuttings
❑irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: IS Bentonite Slurry i ❑ Other(explain under 7g)
mmonitoring ❑Recovery
Injection Well: 7L For each material selected above,,provide amount of materials used:
i
❑Aquifer Recharge El Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier
❑Aquifer Test ❑Stortnwater Drainage
❑Experimental Technology []Subsidence Control 7g,Provide a brief description of(lie'abando nicut procedure:
❑Geotherinal(Closed Loop) []Tracer The well was filled to the top with a
❑Geothermal(Heating/Cooling.Retum) ❑Other(explain under 7g)
�'^ ntonite and concrete!grout slurry. A tremie pipe
a.Date wells abandoned: 4/24/2023 1,R E ENE O was utilized to assure proper application of
5a.Welllocation: AUG 2 5 2023 the slurry.
Cain, Anne E N ,,�;�,ptnorm. rtg uro
Facility/Owner Name Facility lD$(ifa0lAVQ)3Uk# 8.Certification: �/ ?
5066 Harmony Highway, Hamptonville, NC 27020 44—
Physical Address,City,and Zip Signature ofCertirred Well Contractor or Well Owner Date
Irendell 4884111953 By signing this form, 1 hereby cer•lify�;that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A A'CAC 02C.0100 or 2C.0200 Mell Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and thal a copy of this record has beery provided to the well owner.
(ifwell field,one latilong is sufficient) 9.Site diagrmn or additional well details:
36.050572 N -80.755154 ", 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 OFWELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attaclnrellcarstractionrecotd(s)ffasallable.Forurultipleityectiortornon-scalersupplywells
ONLI'uvith the satire cotrstrrtcllorrlabandomnent,ymt can submit one form.
10a. For All Wells: Submit this fonn within 30 days of completion of well
6n.Well 1DO: MW-1 abandonment to the following: I
Division of Watet•Resources,information Processing Unit,
Gb.Total well deplun: 43 (fit.) 1617 INlail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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 fonn within 30 days of completion of well
abandonment to the following: j
6d.Water level below ground surface: Unknown (ft) Division of Water Resources,Underground Injection Control Program,
16361-I,iii Service Centl i-,IRaleigii,NC 27699-1636
NA loc.For Water Supply&lnteetiol 11 lei is: In addition to sending the form to the
Gc.Outer casing length(if lmotvn): (ft.) address(cs)above,also submit one copy of this fonn within 30 days of completion
of well abandonment to the county I health department of the county where
28
6f.Inner ensing/hrbing length(if known): (ft.)
abandoned.
6g.Screen length(if lmown): 15 (ft.)
r
Fonn OW-30 North Carolina Departosenl of Environncntal Quality-Division of Water Resources Revised 2-22-20t6