Rowan_Well Abandonment_20231101 (4)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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-30 is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:wA
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'66 gal.)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used: N/,A
2.Well Construction Permit#: N/A
List all applicable well construction permits .e.UIC,County.State.Variance,etc.)if known
'(i i 7d.Amount of disinfectant used: N/A
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaVPublic IN Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial []Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonitc Slurry i` ❑Other(explain under 7g)
RMonitoring ❑Recovery i
Injection Well: 7f.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 Water-2.00 gallons
❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed loop) ❑Tracer '
Tremie grouted with a Portland mix.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
The well was abandoned in accordance with
4.Date well(s)abandoned: October 03, 2023 15A NCAC 02C .01 I3".�' ll `
Sa.Well location: s"' n� tJ7 Z"i,
Products(SE)Pipeline Corporation N/A NOV i
_ 023
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1615 Jake Alexander Boulevard West, Salisbury,28147 D;;: oetolie�3d;2023
E:1; anx
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Rowan 450 011 By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.01 00 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
+,
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
35.6817472 N -80.5081310 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
Aaachuellcoactnrctionrecord(s)ifatailable.For multiple injection or non-water.upplyivells
ONLY with the same construction/abandonment,you can submit one fonn.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
i,
10b.For Inieetion 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
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abandonment to the following:
6d.Water level below ground surface:4.80 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ce i ter,Raleigh,NC 27699-1636
6c.Outer casing length(if known): N/A (fk) 10c.For Water Supply&Inieetion 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
6E Inner casing/tubing length(if known): 2.0 (ft) abandoned.
6g.Screen length(if known): 13.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016