Lenoir_Well Abandonment_20231113

DocuSign Envelope ID:C751013A-160A-42F5-8966-4BEEAAO3D6OB
•• •••LL 1 aai111•M V I.\1.1iJ1\A. lu4 V......1L11.1.0 For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
HICKORY WELL SERVICES I 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
ISAAC BLACKBURN wells abandoned) r ;
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well): C ' (gal.)
4080C FOR WATER SUPPLY WFT.T.c nlr.V!
Company Name C _ -�t�
2.Well Construction Permit#:
1 107
lc.Type of disinfectant used: ` , --—. -—
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.)iflrnown I O2-
7d.Amount of disinfectant used: 6 9 r\vl l/ k sr-
3.Well use(check well use):
•
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural OMunicipal/Public 0 Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) 'it iesidential Water Supply(single) 0 Sand Cement Grout t ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ISYCcncrete Grout 0 Drill Cuttings
°Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: — 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: If.For each material selected above,,-provide-amount of materials used:
❑Aquifer Recharge. ❑Groundwater Remediation a „t/( ` '� P F,.. ,i' ? s,-',.,,,
❑Aquifer Storage and Recovery ❑Salinity Barrier N O V 1 y 2023
❑Aquifer Test OStormwater Drainage I
°Experimental Technology ['Subsidence Control I it - ^,.-t:o>1 i.;;,
7g.Provide a brief description of tlr"u'aliandoninegl.procedure:
❑Geothermal(Closed Loop) ❑Tracer I to v -/%_,-. 9
❑Geothermal(Heating/Cooling Return) °Other(explain under 7g) re i v e c 4 C , jc b'P ir/ Lt. 5 vole
e
o J -Pt9 r�??-pc.d c.S Jo-0,-'
i
4.Date well(s)abandoned: 1 n-3 (- 2023
5a.Well location:
S Sterling St Prop
Facility/Owner Name Facility ID#(if applicable) 8.Cer' cati
2936 Morganton Blvd . 't p3•D-C 10/: /f-2�
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
1.
Lenoir 2738001598 By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance.with 1 SA 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:
I
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.867.002 N 81.598560 _ 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 construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
62.Well ID#: abandonment to the following:
)
r/ Division of Water Resources,InformationTProcessing Unit,
6b.Total well depth: J (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
// 10b.For Iniection Wells: I i addition to sending the form to the address in 10a
6c.Borehole diameter: _1-1 (in.) above,also submit one copy of I this form within 30 days of completion of well
abandonment to the following:,
I
6d.Water level below ground surface: /V f (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I'
6e.Outer casing length(if known): (g,) 10c.For Water Supply&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
I
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) 1
f
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016