Rowan_Well Abandonment_20231101 (9)

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:w^
NC Well Contractor Certification Number 7b.Approximate volume of water)remaining in well(s): 1'17
(gal)
AECOM Technical Services of North Carolina FOR WATER SUPPLY WELLLS:ONLY:
Company Name 7c.Type of disinfectant used: 'V/A
2.Well Construction Permit#: N/A
List all applicable well construction permits(4e.UIC.County.State,Variance,etc.)iftmowr
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 ❑Munieipal/Public N Neat Cement Grout ❑Bcntonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonitc Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E 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 ❑StonnwaterDrainage Water-2.00 gallons
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Tremie grouted with a portland mix.
The well was abandoned in accordance with
4.Date well(s)abandoned: October 03,2o23 15A NCAC 02C .011311-- ;-
Sa.Well location: "' �' FS 3 �• ,a
Products(SE)Pipeline Corporation N/A ` 1023
Facility/Owner Name Facility 1D#(if applicable) 8.Certification: l
1615 Jake Alexander Boulevard West, Salisbury, 28147 zc .r nctatieAa'32o2s
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Rowan 450 011
By signing this form,I hereby certi)y' that the well(v)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 bees:proWded to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.6815157 N -80.5080680 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)ifavailable.For multiple injection or non-water supply wells
ONLY with the.same�constrtuctionlabandonment,you can submit one form.
M V V�14 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well 1D# 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
10b.For Iniection 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
,t
abandonment to the following: `
6d.Water level below ground surface: 7.84 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I.
6e.Outer casing length(if known): N/A (ft.) loc.For Water Suaaly&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 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