Davidson_Well Abandonment_20231006

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, WELL ABANDONMENT RECORD For Internal Use ONLY:
' 1.Well Contractor Information: WELL ABANDONMENT DETAILS
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J• Hall Jr 7a.For Geoprobe/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 30 is needed. Indicate TOTAL NUMBER of
3224A wells abandoned: I
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NC Well Contractor Certification Number 7b.Approximate volume of water1remaining in well(s): (gal.)
Cascade Drilling . FOR WATER SUPPLY WELLS ONLY:
• Company Name • Chlorine tablets
7c.Type of disinfectant used:.
2.Well Construction Permit#: . '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 1 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout .-f^-^Q^ I;Dfill'•Qftttings
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-0 Irrigation — — -0-Specialty-Grout , ;�.�_, ❑G ve- ---
Non-Water Supply Well: 1. a Bentonite Slurry 1 2 y Ather(explain under 7g)
❑Monitoring ❑Recovery OCT 0 6 LUL3
Injection Well: 7f.For each material selected above,provide anar t of materials used:
gal. Is1�,7Tf
20t. Pr ., .„»7t::.g L
❑Aquifer Recharge ❑Groundwater Remediation ,: - na
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❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer tremmie grout, overdrill, and removed
❑Geothermal(Heating/Cooling Return) DOther(explain under 7g)
. 6-20-23 Doer dl;/led 401d we/17 /dee�e/'
4.Date well(s)abandoned. - 1 SQ a 4L0`e ` Se f Gf seep ems•
5a.Well location: �/✓/V M we
.1�✓ / P/q4+. I
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
Physical Address,City,and Zip Signature of V •
Cy. ell Contractor on Well Owner Date
• �� SUS . "I 1By signing is form, 1 hereby certify:that the well(s)was(were) abandoned in.
' ` County Parcel Identification No.(PIN) 'accordance with 15A 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/minutes/seconds or decimal degrees: 1:
(if well field,one lat/long is'sufficient) •
9.Site diagram or additional well details:
- ' - - '-YOu may use the back of this page to provide additional well site details or'well - -
• ' N W abandonment details. You may also attach,additional pages if necessary.
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CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells '
' ONLY with the-same construction/abandonment you can submit one form.
,I ; jlOa. For All Wells: Submit this,form within 30 days of completion of well
6a.Well ID#: I\IV-3 ,abandonment to the following: I ,
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 • (ft.) • 1617 Mail Service Center,Raleigh,NC 27699-1617
110b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 611 (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: - (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
-4---c 6e.` Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectiol Wells: In addition to sending the form to the
Alliraddress(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(if known): (ft.) abandoned.
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6g.Screen length(if known): 1 0 (ft.)
Form GW-30 , North Carolina Department of Environmental Quality-Division of Water Resources; Revised 2-22-2016
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