Harnett_Well Abandonment_20231024

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETA IIS
Travis Frazier I7a.For Geoprobe/DPT or Closed-LI op 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
4150-A wells abandoned: 1f
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 327 (gal.)
Charles R. Underwood Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#: EH2307-0009
List all applicable well construction permits 0.e.UIC,County,State,Variance,etc.)if known 16 oz
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) •Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: -. - - - _ 7f.For each material-selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement Grout 6 yds
❑Aquifer Storage and Recovery 0 Salinity Barrier 1
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control I'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed top 5-feet of well tile,pumped all of the remaining water out of the well
❑Geothermal(Heating/Cooling Return) 0 Other(explain under 7g)
and filled to the top with cement grout Including the surrounding the excavation around the removed tiles.
4.Date well(s)abandoned: 9/26/2023 r•. ;9
5a.Well location: '
Carolina Commercial Contractors �I C:T 2 /1 2023
,:
Facility/Owner Name Facility ID#(if applicable) S.Certification: ,c P. r',.rC C: ,n:m lira
40 Rawls Club Rd, Fuqua Fuquay Varina, NC 27526 p '-10%05/2023
Physical Address,City,and Zip Signature of Certified W ontractor or Well Owner Date
Harnett •
By signing this form,I hereby certify that the well(s)was(were) abandoned in
County Parcel Identification No.(PIN) accordance with ISA NCAC 02C 00100 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:
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
35.32.2790 N 78.48.5639 W You may use the back of this page tot provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
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.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following:
I Division of Water Resources,Information Processing Unit,
6b.Total well depth: 50 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
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1013.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 20 (in) above, also submit one copy of this.form within 30 days of completion of well
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abandonment to the following:
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6d.Water level below ground surface: 30 (ft.) Division of Water Resources,,Underground Injection Control Program,
_ 1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Injection 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 where
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016