McDowell_Well Abandonment_20231024

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Singleton Environmental, Inc. 7a.For Geoprobe/DPTor Closed lLoop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
Chris Singleton wells abandoned:
+
7b.Approximate volume of water remaining in well(s): 11'65
NC Well Contractor Certification Number PP l; (gal-)
3328—B FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: ,
List all applicable well construction penn its(1.e.UIC,County,State,Variance,etc.)ifknoww
7d.Amount of disinfectant used:'
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) liResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
FMonitoring ❑Recovery
Injection Well: X For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 11 bags of bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 4 bags of concrete
❑Experimental Technology El Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite was poured to a depth of 3 ft and
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
concrete was poured!to the surface.
4.Date well(s)abandoned. 10/11/23
5a.Well location:
Samir's#2
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Facility/Owner Name FacilitylD#(if applicable) 8.Certification: O C T J /' 2023
2815 Sugar Sug Hill Rd, Marion, NC 28752 � tn��r;r;z�s^n fir,-;✓_,: ..� ,� ;.�
Physical Address,City,and Zip Sign of Certified Well Con r or Well Owner :' ( rDhtea
McDowell
By signing this form, I hereby cerl�fv' 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I t provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well deltails:
35.6487 N -82.0331 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(1)ifavailable.For multiple injection or non-water supply wells
ONLY with(lie sane constructionlabandonment,you can submit one form
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ED#• MWS 1,2,3,4,6,7,8 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 390 A) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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: I
I
40.55,35.55,41.5a.M1,41.15,40A$3 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) ,
/� 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A (ft.) 1Oc.For Water Supply&Injectioi Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
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of well abandonment to the county; health department of the county where
6f.Inner casing(tubing length(if known): N/A (ft.) abandoned I
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6g.Screen length(if known): 20' each well (ft.)
Form GW-30 North Carolina Department of Environmental Quality Division of Water Resources Revised 2-22-2016
Pam Q Y-

f �
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Singleton Environmental, Inc. 7a.For Geoprobe/DPTorClosedlL,op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed Indicate TOTAL NUMBER of
Chris Singleton wells abandoned: II
7b.Approximate volume of water remaining m well s. 11.03
al.)
NC Well Contractor Certification Number pP i g� O' (g
3328-B FOR WATER SUPPLY WELLS11 ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(1'.e.UIC,County,State,Variance,etc.)if larown
7d.Amount of disinfectant used:'
3.Well use(check well use): i.
Water Supply Well: 7e.Sealing materials used(check allthat apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
01ndustrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout I ❑Brill Cuttings
01ni ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: _ ❑Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 7 bags of bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
3 bags of concrete
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of'the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite was poured to a depth of 3 ft and
❑Geothermal Heatin Cooling Return ❑Other(explain under 7
concrete was poured Ito the surface.
4.Date well(s)abandoned: 10/11/23
5a.Well location: `r i-'r; V;?Z
Kay Lees Express U L 1 11f= 2023
Facility/Owner Name Facility ID#(if applicable) 8.Certil"icad
435 West Henderson St, Marion, NC 28752
Physical Address,City,and Zip S e of Certified Well Co for of,Well Owner Date
McDowell
By signing this form, I hereby cevtfv 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: f i
(if well field,one lat(long is sufficient) 9.Site diagram or additional well details:
35.6779 N -82.0111 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
Attachwellionstrwctionrecord(.Y)ifavaiWIe.For multiple injection or non-watersupplywel&
ONLY with the same constructionlabandonment,you can submit oneform
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MWS 1,2,3,4,6,7,8,9 abandonment to the following:
Division of Water Resotrces,Information Processing Unit,
6b.Total well depth: 180 (it.) 1617 Mail Service Center,Raleigh,NC 27699-1617
I,
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6e.Borehole diameter• 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: ! !
4
a ari sr,, .,,.e,s.,o.,a.,x.a3Aa,i. Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service C�en4 er,Raleigh,NC 27699-1636
N/A 10c.For Water So ply&Injectio'n Wells: In addition to sending the form to the
tie.Outer casing length(if known): N/A address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county' health deparhnent of the county where
6f.Inner casing/tubing length(if known): N/A (ft.) abandoned f
6g.Screen length(if known): 10 to 15 each well (fL)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resourcesl Revised 2-22 2016