Davidson_Well Abandonment_20231113

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WELL ABANDONMENT RECk,2D0 7 ?023 For Internal Use ONLY: l
1.Well Contractor Information: NUU� WELL ABANDONMENT DETAILS
Frank Beecher - NO DEQ/D.WR . _- ____ _-__Y_
�ritrel Office 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
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NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'88 (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 I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 ❑Municipal/Public 0 Neat Cement Grout 1 e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
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❑Induslrial/Cotnmercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
❑Irrigation z--- . ^F' 5.F;r, "•+\ , 0 Specialty Grout 0 Gravel
Non-Water Supply Well: t'b .Y,.,.'',..,.:;; V I a••'` 0 Bentonite Slurry 0 Other(explain under 7g)
Monitoring ❑Recovery
Injection Well: N U V 1 ZlZJ 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 1,_.• Bentonite Chips-40.0 lbs.
❑Aquifer Storage and Recovery ❑Safi iity Bam' c'.;:.;: t�
4L11=,1- Water-1.0 gallons
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Slowly filled well with bentonite chips ensuring that Bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
was not occuring,hydrate bentonite,and topped with concrete.
4.Date well(s)abandoned: 10.05.2023 The well was abandoned in accordance with
5a.Well location: 15A NCAC 02C .0113".
Speedway-7926 N/A
Facility/Owner Name Facility ID#(if applicable) S.Certification:
407 Randolph Street Thomasville, NC,27360 -� i___ f3`; 10.31.2023
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Davidson By signing this form,I hereby certify 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: ,
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.8762667 N 80.0773146 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 records)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
n/�`A/ 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 'V I V V-2 abandonment to the following: - --
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: 20'0 (ft.)
lOb.For Injection 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:
Division of Water Resources,'Underground Injection Control Program,
6d.Water level below ground surface: 8.47 (ft)
p 1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): NA (ft.) lOe.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
6f.Inner casing/tubing length(if known): 5.0 (ft.) abandoned.
6g.Screen length(if known): 15.0 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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