Rowan_Well Abandonment_20231101 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 7a.For Geoprobe/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 3d is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:",' I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining i in well(s): 1'04 (gaL)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State.Variance,etc.)iflaeoum
7d.Amount of disinfectant used: 1 N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public H Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Hcating(Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout r ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ! ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Portland-27.07 pounds Bentonite-1.13 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Water-2.00 gallons
❑Experimental Technology ❑Subsidence Control j
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
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❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Tremie grouted with 'a portland mix.
The well was abandoned in accordance with
October 03 2023 _x.-
4.Date wells abandoned: , in
c) 15A NCAC 02C .0113". �=�• `i�
Sa.Well location: NOV
Products(SE)Pipeline Corporation N/A 2 0 2T
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1615 Jake Alexander Boulevard West, Salisbury, 28147i�r t•s,,,
October 30,2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Rowan 450 011
By signing this form,I hereby cerlih that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constriction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has beef provided to the well owner.
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.6819354 N -80.5078785 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
Attaclnvelicorxviructiourecord(v)ifavailable.Formubiple injection ornon-watersupplywells
ONLY with the same constructionlabandanment,you can submit one form.
1t�I`tt, 10a. For All Wells: Submit this form within 30 days of completion of well
V'6a.Well ID#• f V V-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 (fL) 1617 Mail Service Centcr,Raleigh,NC 276994617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter• 2'0 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface• 8.65 (R) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(If known): N/A (fL) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
address(es)above,also submit one copy pf this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): 1.0 (ft.) abandoned.
6g.Screen length(if known): 14.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016