Union_Well Abandonment_20230912

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Norris Lanard Love 7a.For Geoprobe/DPT or Closed-J:aop Geothermal Wells having the same
Well ContractorName(or well owner personally abandoning well on hia/her property) well construction/depth,only I OW-30 is needed Indicate TOTAL NUMBER of
4082-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 75 (gaL)
Love Well & Pump Supply, LLC FOR WATER SUPPLY WELLS ONLY:
CaapanyName 7c.Type of disinfectant used: chlorine
2.Well Construction Permit ti: 23-213
List aft applicable well constructlan permits#.a WC Crotty,Skrie,Parlance eta)jfAnom 5 Ibs
7d.Amount of disinfectant used: ,
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check at that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Gr��°°ut .,. —i,� ElBentonite Chips or Pellets
❑Geothemurl(Heating/Cooling Supply) eResidential Water Supply(single) El Sand Cement Gina! �r V�Dzyy Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete trout Ld-Ai(1 Cuttings
OIrrigation ❑ specialty Grout S E P l 2 12n?�b Gravel
Non-Water Supply Well: a Bentomte Slum ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Inlectlon Wells_ -- __ .. ._ ___. ..-.. _-- 7L FOr each material set' d atiov@L,ernvide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation .full grout (8) 40#bags -[]Aquifer Storage Storage and Recovery ❑Salinity Barrier
0AquiferTest ❑StormwaterDrainage hole plug (1) 50#bag
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer �
❑Geothermal(Heating/Cooling Coolie Return ❑Other ex lain-der7 8/14/23 dug out around the well and removed
pump. 8/16/23 used 8 bags of grout and 1 bag
a.Date well(s)abandoned: 8/16/2023 hole plug. Filled the well from the bottom to
SR.Well location: the top and seal itroff_completely. Then covered
Rachel LeClerc
Facility/Owner Name Facility]D#(if applicable) 8.Certification:
522 Buford Shortcut Rd. Monroe NC 28110 8/16/23
Physical Address,City,and Zip Signanae ofCcrtified Well Contractor cr Well.Owner Data
Union 04-168-022G By signmg this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel IdentificationNo.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beA provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well detalls:
N W 'You may use the back of'ihis 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 SUBMITTAL INSTRUCTIONS
Ad=hwellconshuctionrecord(s)Vavailabla For multiple beectionornon-watersupplywells
ONLY with the same cons!ructionlabandonment,you can submit onefirm. 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well M#: n/a abandonment to the following-
Dlyl on,of Water Resources,Informsdon,P,rocesdngtUnl%
90 1617�Mall Service Center,Raleigh,NC 27699-16175
6b.Total well depth: (ft)
10L For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter• 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 30 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): n/a (D,) 10e.For Water Supply&Infection 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 when
fit:Inner casing/tubing length(if known): n/a ( ) abandoned
G
6g.Screen length(if known): n/a (fL)
Form GW-30 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016