Randolph_Well Abandonment_20231113

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPI 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
wells abandoned:
2957-A
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): _— _ (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
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Company Name 7c.Type of disinfectant used: I HTH Chlorine N ; r ��
2.Well Construction Permit#: 2023-00003018 3
List all applicable well construction permits(1.a.UIC,County,Slate,Variance,etc.)iit knoam 10 oZ
7d.Amount of disinfectant used:!
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check;all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation- ❑ Specialty Grout ❑Gravel
Non-Water Supply.Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete grout 3 cubic yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Poured concrete directly into well and filled to top
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
of casing terminated at 3' below land surface and
a.Date well(s)abandoned: 11-6-23 capped with 2'thick concrete plug.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility tF#(ifapplicable) 8.Certification:
5536 Julian Airport Rd. Liberty, NC 27298 ( #12957--A 1117/23
Physical Address,City,and Zip Signature of Certified Well Con Actor or Well Owner Date
Randolph 8707990472 By signing this form, 1 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
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.,
(ifwell field one IaUlong is sufficient) 9.Site diagram or additional well details:
35.888949 N 79.644709 `,1, 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)ifavoilable,Forum/lipleinjection ornon-watersupply wells
ONLY with the same constructionlabandonmem,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• SW 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 240 (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: 6 (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: N/A (ft.) Division of Water Resources',Underground Injection Control Program,
1636 Mail Service`Center,Raleigh,NC 2 769 9-1 63 6
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6e.Outer casing length(if known): N/A (ft.) 10c.For Water Suooly&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
611 Inner casing/tubing length(if known): N/A (ft.) abandoned. i
6g.Screen length(if known): N/A (ft.)
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Form GW-30 North Carolina Department of Enviromnental Quality-Division of Water Resources Revised 2-22-2016
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