Stanly_Well Abandonment_20231122

WELL ABANDONMENT RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
John W. HuneyC . 7a.Number ofwells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-it,"ter., supply ivells ONLY with the same
2465-A � ;; , •
carrstrucNan/abatrdomnent,you can subm}r one form.
t 7b.Approximate volume of water remaining in well(s): 975 (gal.)
NC Well Contractor Certification Number
L
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type ofdisinfectantused. Granular
2.Well Construction Permit#:
List all applicable wellpGrmits(i.e.County,Slate,Variance,Injectior;etc.)ifknown 1 /2-lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply),:.
❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout El Bentonite Chips or,P_ellets
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Ceinent Grout ❑Dry Clay
❑lndustrial/CommercW ❑Residential Water Supply(shared) ❑Conciete Grout ❑Drill Cuttings
❑Irri ation ❑'Specialty Grout ❑Gravel
Non-Water Supply Well: 0 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amountpf materials used:
❑A uiferRechar a ❑GroundwaterRemediation 150 IbS:Bentonitt?SiUrry '`
9 g
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 50 IbS- Bentonite Chips NnU d 23
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment pr4Fdure;.:
[]Geothermal(Closed Loop) ❑Tracer Well was pumped with bentonite slurry through' a
❑Geothermal(Heating/Cooling Return) Other(explain under 7g)
a.1"Aremie pipe extending down into well from 80'
a.Datewell(s)abandoned: 4/10/23 up•to 3' below surface. !Remaining 3'was gravity
5a.Well location: .filled with bentonite chips.
Jill McLain
Facility/Owner Namc Facility IDH(if applicable) 8.Certification: -
40268 Airport Rd, Albemarle 28001 4/25/23
Physical Address,City,and Zip signO&
of Certified Well Contractor orol,ell Owner. Date
Stanly 21248 By signing this form, I hereby certiry that the ivell(s)ivas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Constnnction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: p
(ifwell field,one lattlong 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 ivell construction records)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonmenl,you can submit one form 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,
6b.Total well depth: $0 (ft.)
1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in IOa
above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 6 (in.) abandonment to the following: `
15 (g) Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface:
1636 Mail Service Center,Raleigh,NC 276994636
G
10c.For Water Sunnly&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (it.) 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
6E Inner casing/tubing length(if known): (ft-) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

# 9—Well Diagram 6" Well Diameter
No Steel Casing
Removed
0' to 3' Filled with
Casing Depth Bentonite Chips'
Unknown
3' to 80' Pumped
with Bentonite
80'—Total Well Depth