Iredell_Well Abandonment_20231122

WELL ABANDONMENT RECORD For Internal Use ONLY: 1
This form can be used for single or multiple wells
1.Well Contractor Information: WELL'ABANDONMENT DETAILS _ .
John W. Huneycutt. 7a.Number of wells being abandoned: 1
•
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with 'the 'same
construction/abandonment,you can submit one form.
2465-A i. •
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 426 (gal.)
Derry's Well Drilling, Inc. • FOR WATER SUPPLY WELLS ONLY:
Company Name • '7c.Typeofdisinfectantused: Granular
2.Well Construction Permit#.
2023-34023
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)iflmmvn :1I2 Ib:
70.Amount of disinfectant used:
3.Well use(check well use): •
Water Supply Well: • 7e.Sealing materials used(check all that apply):. ' s
❑Agricultural ❑Municipal/Public . O.Neat Cement Grout ,... .- __ El Bentonite Chips_or Pellets
0 Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) . 0 Sand Cement Grout 0 Dry Clay
❑industrial/Commercial ❑Residential Water Supply(shared) ❑.Concrete Grout 0 Drill Cuttings
❑Irrigation . -o Specialty Grout 0 Gravel
Non-Water Supply Well: . El Bentonite Slurry 0 Other(explain under 7g) •
❑Monitoring ❑Recovery •
Injection Well: If.For each material selected above,provide amoLnt.ofmaterials used:
❑Aquifer Recharge ❑Groundwater Remediation • 1,050 Ibs-Bentonite Slurry r ',..,—. ,.., ';. 't t_-' a
•
❑Aquifer Storage and Recovery ❑Salinity Barrier (, �.
450 lbs- Bentonite Chips
❑Aquifer Test ❑StormwaterDrainage NOv 9 2 2023
❑Experimental Technology 0 Subsidence Control 7g,Provide.a brief description of the abandonmen*- rocedu 7,._,,,.,,,;_ , y
❑Geothermal(Closed Loop) ❑Tracer • Well was pumped with';.bentonite slurrptlattigb
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
a 1."tremie pipe extending down into well from 305'
4.Date well(s)abandoned: 11/8/23 up to 7' below surface.;, Remaining 7'was gravity .
5a.Well location: . filled with bentonite chips. Qo5-:oV.'WG(-t2l :• added
Cambridge Properties, Inc. ill', h` dra-le;
8.Certification: ` 7
Facility/Owner Name FacilitylD#(ifapplicable) / � /'t&J •
1212 Coddle Creek Hwy,Mooresville 28115(Harris Bros Family Prop,Lt2) 4 tt' • 7/7 , _ ..--11/16/23 -
Physical Address,City,and Zip Sign of Certified Well Contractor or'W Owner Date
Iredell 4666-75-3285 • 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.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:
• You may'use the back of this page,to provide additional well site details or well
N W.. abandonment details.-You may also,attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED • SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply .
welts ONLY with the same construction/abandonment,you can submit one forne 10a. For.All Wells: Submit this:form within 30 days of completion of well
abandonment to the following: •
• 6a.Well ID#:
Division of Water Resources,Information Processing Unit,
305 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.) •
10b:For Injection Wells: In addition to sending the form to the address in l0a
6 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (ui.) abandonment to the following: I ,
21 Division of Water Resources,'Underground Injection Control Program,
6d.Water level below ground surface: M.) ". 1636 Mail Service Ceenter,Raleigh,NC 27699-1636
IOc.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): O • 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
i
6g.Screen length(if known): (IL) -. -
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

# 9—Well Diagram 6" Well Diameter
1 No Steel Casing
•
Removed
0' to 7' Filled with
Casing Depth Bentonite Chips
•
Unknown ..
•
•
•
•
•
•
•
•
•
•
•
•
7' to 305' Pumped •
with Bentonite •
. -
•
305'—Total Well Depth
..................