Rowan_Well Abandonment_20231006 (3)

WELL"ABANDONMENT RECORD For internal Use ONLY:
1.Well Contractor Information: ." WELL ABANDONMENT DETAILS
George"Thomas Ammons Jr 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same .
Well ContmctoiName(or well owner personally abandoning well on his/her property) well construotion/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Wells abandoned:
2035A- ;
NC Wcq Conuactor Certification Number "• 7b.Approximate,volume of water remaining in well(s): �1�r• (gal.)
:EHC.Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name HTH .
.7c.-Type of nfe disictant used:
2:Well Construction Permit#: 3967'11' . -_
List a(7 applicable it-ell co. tnrction permits(i.e.U1C County.Stare,icariance,etc.)ijlmour" 3 0Z
7d.Amaunt:of disinfectant used:'
3.Well use(check well use):.
Water Supply Well: ." 7e:Scaling materials used(check all'tha(apply):
OAgricultursl: OMunidipal/Public ❑Neat Cement Grout ; e"Bentonite Chips oi•Pellets "
❑Geothermal.(Heating/Coolitig Supply) eResidential Water Supply(single) . "❑Sand CeinentGrout� - r�^❑ Clay-
❑lndustriaVCominercial OResidcritial.Water Supply(shared). S:Concretc Grout-��� P•L•.•t' [I•Drill Crittings
❑lni ration '❑Spebialty Grout n" ❑Gravel
Non:Water Supply Will: _ ❑Bcnfonitc"Slurry.O C T .0 6 .2023.-O Other(explain ender 7g)
❑Monitoring_. ❑Rccovoy.
Injectian.Well: "7f.For each-dtalaria}"selected al�o%pk-6 a
pmount of materials used:
❑Aquifer Recharge " ❑GroundW;ttcrRemediatiorl• y:'Jy Bentonite
❑Aquifer Storage and Recovery" ❑Salinity Barrier. r
'❑Aquifer•Test ❑StormwaterDrainage 2 COnC�et@,
❑Experimental"Technology ❑Subsidence Control-
lg.Provide a brief description of the abandonment procedure:
OGeotNemial,(Closed.Loop) OTracer
Disinfect and then.slow pour•bentonite.and tapped with MO.feet
[]Geothermal(Heating/Cooling Return) . ❑Other(explain,under 7g)
of,"land surface.". :
8/24/2023
4.Date Wells)abandoned:
52.Well'location:' . .
Hudson Capital.Properties ..
Facility/OwnerName Facility IDq(if applicable) •
8 Ccrtifi ti
2000-Old Beatty Ford.'Road, Kannapolis;_28023 9-21-23 :
Physical Address; ,an
d Zip " Signature crtif We Contractor or Well Otvncr 'Date
Rowan-::. . .147-025 '.
Bp signing this jorii,l hereby cerq&.thal the we.11(s):tros(werej abandoned h.i
County Parcel ldcnlification No.(PIN) accordance with 1 SA NCAC 02C.0100 or:2C.0200 Will Consiraetiori.Standurds
and drat a copy"ojthis recoiV has been provided to the:well owner.
56:Latitude and longitude_inAegrecs/mimics/secoads.ordecima)degrees: i.
(if well field,one lat/long is sufficient) '
9.Site diagram or additional well details: :-
:N` . W. Y . "
You may use the back,of this page to provide additional well site details or Well-
. �" a may.also act nal pages if cessaty.,, : .. .
abandonment defails:.You attach ad ne
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED' -. ' SUBMITTAL INSTRUCTIONS
' 'daurGx•elirmrsrnrcrionreiurd(s)ijavailuble.'Fnrnm(riplemjeriiunar�un-irruersirppl�;nrlls" ., - '' - - ''
ONLY rrilh the same c onslnrcrion/abandminrenl,you can mtr mil air farm: .
.. . . .10a.,For.All Wells' .Submit.this form Within 30 days of completion of.well
6a Well y��'y� abandonment to the following:
Division.of Wafer Resources,Information Processing Unit,.
37 . 1617'Mail Service Centcr,'Raleigh;NC 27699-1617 -
•6b,Total well depth: (ft.)
u IOb.For iniection Wells: In addition to sending.the:form to.the address in 10a
6. above,'also submit one copy of this form within days.of completion"of well
6.c.Borehole diameter: (in.) . ,
abandonment to the following: .
bd.Water level below•ground surface 30.5" (ft.) Division of Water Resources;iUnderground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-]636
6e:Outer casin length(if known):
U N.K 10c.For Water Suooly&lniecti6n Well3: In addition.to sending the form to the"
g (fit.)
addresses)above,also.submit one copy of this fotm.within,30 days of completion
of""well abandonment to the county health department of the county where -
6f.Inner c. n' ' tubing length(if brown) ".Unk (it:) abandoned. ;
6g.Screen length(if kriown): U N K •(ft.)
Form GW-30" North Carolina Dc artmcnt ofEntironmcntal alit ( 1 •p Q" ' y-Division'of Water Resources Retiscd 2-22-2016
i