The URL can be used to link to this page

Home My WebLink AboutYadkin_Well Abandonment_20231101 • WELL-ABANDONMENT RECORD For.intemal Use ONLY: . •. ' ..,. • I I,•Well Contractor Information: • •• !!�� WELL ABANDONMENT DETAILS r�n �� (/C��t'�`� 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or ell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-90iis needed. Indicate TOTAL NUMBER of A �n"�}c� // • wells abandoned: f�t7(c7 GX Lam- ..--% . NC Well Contractor Certification Number 7b.Approximate volume of.tvater(remaining in tvell(s): • 5 (gal) YADKIN WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: et_ L'' tr� ' 2.Well Construction Permit#: List all applicable well construction permits•(i.e.UIC,County,State,Variance,etc..)If known 7d.Amount of disinfectant used: t"N. . .:....07r 3:Well use'(check well use): 11'a(e,t•1Sypplyl;Vell:,-.:. _ •_. .. • .. 7e.Sealing materials used,(check all that ajipl}r):•''_,•' -, 1 ❑Agricultural ❑MMunicipal/Public 0 Neat Cement Grout ❑ Bentonite Chips or Pellets - ' ❑•Geotheirital`(Heating/Cooling'Supply) ItResidential Water Supply(single) ❑Sand Cement,Gr'out-:,-,, -._ 0 Dry Clay ' ' ❑Industrial/Commercial - ❑Residential Water Supply(shared) l 'Concrete Grout`""" r- <•s' ;.�-r''",%..-2, D'DrillCuttings ❑Irrigation .. . ❑ Specialty GroutN ?'��[ Gravel NOri•-1\'atei•Supp) Well:‘ - ' ` - • ' - v . 0 Bentonite Slurry 2023.• ,:❑ Qther(explain under 7g) '❑Monitoring ❑Recovery • rn-C_, 'ulicction Well: 7f.For each material.selectedrabove,provide amount of materials used:. L:.girifer Recharge ' ❑Grodndwater Remediation , "' ISI r�P tllV�� 0Aquifer Storage and Recovery ❑Salinity'Barrier" • . ❑Aquifer Test ❑Stormwater Drainage to }( S icN4/'€_ • - • t 1 ❑Experimental Technology ❑Subsidence Control. 7g.Provide a brief description of the abandonment procedure: ' ❑Geothermal(Closed Loop) OTracer t} (n� �r, f � •. ,❑Geotherma((Heating/Cooling.Retum), ❑Other(explain under 7g) ?�LrT J Td vel --fone1 a'1 .'� Utv. .. . {F nn ,om, -fie t �ettipA �-1 C - 4.Date well(s)abandoned: 1 `` r7� P. tUm O n • • 5a:Well location: ' • . . ii •fli1A / • ('DC/.�-' .. - • . ricrlity/Ownerblame - FacilityiD#(if applicable) 8.Certif tion: ill •ri�.�:. = V : ' ;,.' Riiii,-„),-.. ei Physicat.Addfe6S;City;and:Zip-• 1-.•t ' •• • : • .igndture ofCeitifed Wehr;;.ctor or Well Owne'r Date • p. By signing this form, hereby certi.0 that the svell(s)was (were)abandoned in Cquhh' Parcel Identification No.(PIN) .. accordance with 1SA NCAC 02C.0100 on2C,O100':Well Construction Standards and that a copy'of this record has been provided loathe well owner. • Sb.,Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifavell-field,one lat/long insufficient) 9.Site diagram 22 // or.additional well details: J fQ IqRv( • N `SD. $ag/ 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 Adach well construction record(s)ifavailable. For multiple injection or non-watersupplywells .. Orn1':with the sane construction/abandonment,you can subinitone form. • 10a. For All Wells: Submit this form within 30 days of completion of well Ga.Well ID#: • . abandonment to the following: ``�. t I _ Division of Water Resources,Information Processing Unit, Gb.Total well depth: 6e�. (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 • ,`/�� ff • • 10b.For Iniection Wells: In addition to sending the foam to.the address in 10a 6c.Borehole diameter: l V ' (in.) above,also submit one copy of this form within 30 days of completion of well abandonment to the following; ___- - - :___ 6t1::Waiter Eret'e.b'elowgr•ound surface: '' (ft) Division of Water Resources,Underground Injdction Control'Program, ' : • 1636MailSerditeiCeo[cr;T2aleigh;NC27699-`1636 • • 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 *here 611Inner 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 2-22-20I6 • . ; WELL ABANDONMENT RECORD ForintemalUseONLY: • csa :. Well Contractor Information: • - WELL ABANDONMENT DETAILS I �� " -- :. i(�P'h�f�ir� /ItOS (it� 7a.For Geoprobe/DPT or Closed-loop Geothermal Wells having the same ' Well Contractor N me(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of t wells abandoned: ,• ON f,Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): _(gal.) O YADKIN WELL COMPANY INC. . + FOR WATER SUPPLY WELLS ONLY; ;i -q �: Qt.i•tpanyNne • ..• =• 7c.Typeofdisinfectantused: ��ib1�1/. 2.tVell'C nsfruction Permit#: Li.�l all applicable well construction permits'(i.e.UIC,County,State,Variance,etc.)if i • 7d.Amount of disinfectant used: L 0, 0 3.Well use(check well use): . • Water Supply Well: . 7e.Sealing materials used(check all that apply): r ❑Agricultural ❑Municipal/Public ❑Neat•Cement Grout 0 Bentonite Chips or Pellets 0 ❑Geothermal(Heating/Cooling Supply) 1 sidential Water Supply(single) 0 Sand Cement Grot:-.:(,,I.:::::r° -"❑ Dry Clay ' ' i ❑Industrial/Commercial • ❑Residential Water Supply(shared) 13JConcrete Grout r_ t - ' 1'. ❑LDiill Cuttings ❑Irrigation 0 Specialty Grout NOV k) 2023 0 Gravel Nd,d-Rater Supply Well: 0 Bentonite Slurry l+ ❑ Other(explain under 7g) 1 Monitoring ❑Recovery ,51 .- Lmir.ction Well: n � . 7f.For each material selected•a_bov;'e;.'prtivideamount of materials used: .�Aquifer Recharge ❑Grotindwater Remediation 3 f/ r,j- J -:1 quifer Storage and Recovery • I ❑Salinity Barrier' C G+ N • ❑r.quifer Test ❑Stormwater Drainage (� t • ❑e.xperimental Technology ❑Subsidence Control'. 7g,Provide a brief description of the ab donment procedure: a ❑,.reothermal'(Closed Loop) ❑Tracer b S ❑3eothennal(Heating/Cooling Return). ❑Other(explain under'7g) Qfn..)e t7� -'D•,K-e s :. .v 'Ot?.. . . s 4s'Date ivell(s)abandoned: ' f. .dufd eki-4-1-.: Ay,- -4,--:?c,...tc---i, 5ai Well-1o.cation: •• ' • iZ Facility/Owner Name c,✓ FacilitylD#(ifapplicable) 8.Certift��ion: i , •® 0S 2 i ( 0fC idMil . Physi iclAcalAddress;City,'and ZipN Signature of Certified el► or or, ell Owner Date ` r ",A/ .-70 , , By signing this form, I hereby cent fy that the well(s)was (were)abandoned in • Couhh' Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C.0100 or 2C.0200 Well Construction Standards • •I'' and that a copy of this record has been provided to the well owner. 51i,,Lttitude and longitude in degrees/minutes/seconds or decimal degrees: (iC`vell field,one lot/long is sufficient) 9.Site diagram or additional well details: - . 3 10 t l(l t.'/p' N "O ic- r?el W You may use the back of this page'to provide additional well.it^ or well . abandonment details. You may also attach additional pages if necessary. �.5NSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Al pch well construction record(s)ifavoilable. For multiple injection or non-watersupply wells Ori'LY with the same construction/abandonment,you can submii'one form. • 10a. For All Wells: Submit this iform within 30 days of completion of well Ga.Well IN: abandonment to the following: • i (' • Division of�Vatci Resources;Informatron Processing Unit, Gb.'Dotalp ell depth: l . (ft.) 1617 Mail Service Centers Raleigh,,NC 27699-1617 10b.For Infection Wells: In addition to sending the'form:.to the address in 10a 6cj Borehole diameter:, O (in.) 'above, also submit one copy of this form within 30 days of completion of well C abandonment to the following: ✓� • UI 6d.:\hater level below ground surface: (!o� (ft.) Division of.Water Resources,Underground Injection Control Program, -- • 1636 Mail Service Center,Raleigh,NC 27699-1636 Q • i O. 6e Outer easing length(if known): (ft.) - 10e.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 l •6f.Inner casing/tubing length(if known): (ft.) abandoned. • .a .. VI 6g,Scr•een length(if known): — (ft.) • 9�s • c u,rt GW-30 North Carolina Department of Environmental Quality-Division of Water Resources j - Revised 2-22-2016 ` 0 0 -