Sampson_Well Abandonment_20231024

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WELL ABANDONMENT RECORD• For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS; .
Arthur D Cannady 7a.For Geoprabe/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
21 27-A wells abandoned: I '
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NC Well Contractor Certification Numbers Well.
Approximate volume of water remaining in well(s): 17 (gal.) .
VY Cannady Brothers ell Drilling FOR WATER SUPPLY WELLS ONLY:
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Company Name • , 7c.Type of disinfectant used: Ste. ,rn I ne
2.Well Construction Permit#: 19-074 . .
List all applicable well construction permits(Le.UIC,County,Stale,Variance,etc.)ifknoum -
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7d.Amount of disinfectant used: .3 oz
.3.Well use(check well use): • `
Water Supply Well: • 7e.Sealing materials used(check all that apply):
❑Agricultural DMunicipal/Public , 0 Neat Cement Grout ' .A Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) liResidential Water Supply(single) 0 Sand Cement Grout•,. .. ❑'Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) 0 Concrete Grout ; b.i.,,n,S,.,,G,. r; tl d�A,t7,1 jrill'cCuttings
❑Irrigation ; 0 Specialty Grout ' 1 t1 ❑Geavel
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_ Non-Water Supply Well: ❑Bentonite Slurry OCT C T 2 �'. 202�1 Other(explain under 7g)
. ❑Monitoring ❑Recovery .. • .- ---- -- -
Injection Well• 7f.For each matedtalrsel`eetedtafove,.,prpvidF;amaunt of materials used:
DAquifer Recharge ❑Groundwater Remediation • . 50 lbs Dt"i.'"� i3
❑Aquifer Storage and Recovery ❑Salinity Barrier .
• ❑Aquifer Test • '❑Stormwater Drainage i, .
❑Experimental Technology •❑Subsidence Control ' 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) '❑Tracer Attempted"to 'remove,basing (unsuccessful)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) ,
Pour sterline,•poure,d loentonite chips and water
a.Date well(s)abandoned: 9/27/23 cutoff casing 1.5 ft below gorund level -
5a.Well location: •glued cap, addition hole plug on top
.Blanca Campos . .
Facility/Owner Name Facility iD#(if applicable) S.Certifica' .
89 Patterson Lane, Salernburg NC 28385 ; ; 9-28-23
Physical Address,City,and Zip a of C died Well Contractor or Well Owner Date
Sampson 06-017-335-901 By signing this form,7 hereby Bert j that the well(s)was (were) abandoned in •
CountyParcel Identification No.(PIN) accordance with ISA NCAC 02C,0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude arid longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lallong is sufficient) 9.Site diagram or additional well details:
35.026894 N -78,452073 • W 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 OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS' •
Attach well construction record(s)iflavailable: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 1D#: •
abandonment to the following:
• Division of Water Res Iurces,Information Processing Unit,
1 00 .1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 00 i
10b.For infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 5'75 (in.) above,also submit"one copy of this form within 30 days of completion of well
abandonmentE
to the following:. i ,
35 Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636•Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): 85 (ft.) •10c.For Water Supply&Iniection 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 casingltubing length(if known): abandoned.(ft.)
6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
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