Rowan_Well Abandonment_20231215

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Alfred Kiesl i ng Jr 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 I GW-30 is needed. Indicate TOTAL NUMBER of
3266-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of watef remaining in well(s): r ''
B & K Well Drilling Inc FOR WATER SUPPLY WELLS ONLY: C j 202,
Company Name Chlorine �n1i%Fr, aim L,
7c.Type of disinfectant used:
2.Well Construction Permit#: 31 y 9 s-s `
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
I
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public �ht Cement Grout Ja'13"entonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout + ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) Zi-e6ncrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:? nn
❑Aquifer Recharge ❑GroundwaterRemediation �I P^c ?Y/✓
❑Aquifer Storage and Recovery ❑Salinity Barrier -/ e /
❑Aquifer Test ❑Stormwater Drainage /!,I 6017 L `�
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of th abandonmentprocedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:
5a.Well location:
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
'ZIP M.,g/'"0 . ��>6g. - �3
steal Address,City,and Zip ([ Si aturc of ified Well ontractor o;�fh.t
ner Date
By signing this form, I hereby certhe well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC 02C i 0100 or 2C.0200 Well Construction Standards
Sb.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 hit/long is sufficient) 9.Site diagram or additional well details:
N 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-walersuppty 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
6a.Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: a (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: (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
i
6d.Water level below ground surface: C�' (ft.) Division of Water Resources l Underground Injection Control Program,
1636 Mail Service i Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) lOc.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
6E Inner casing/tubing length(if known): V (ft.) abandoned.
I ,
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
�° ANUONMENT RECORD k , :r
North Carolina Department of Environment and Naturat Resources-Division of Water Quality ?Oil
' ' WELL CONTRACTOR CERTIFICATION# �o
6. WELL DETAILS: �
.�
1•WELL j0 k-a )'A I try L a.Tufai Depth P' ft. Diameter. �. in.
•l b.Water Level(Below Measuring Point): ft-
Well Contractor(Individual)Name ft above land surface.
2 O X asN Measuring point is _
i
Well Contractor Coinpany Name g• CASING: Length Diameter
i! !a Shyri Jls ForeL
Street Address _ft. in.
A 14 a.Casing Depth(if known):;
G in.
Zip Code b.Casing Removed• -
City or Town State p f.
7. DISINFECTION:_ C�'It6v�►'t t
Area code Phpne number (Amount of 65°1075%calcium hypochlorite used)
' r 8. SEALING MATERIAL,
2.WELL INFORMATION: . '
SITE WELL ID# (if applicable) ��pat r merit Sand Cement.
STATE WELL PERMIT# (if applicable) Cement _ib. Cement lb.
water gat. water aal.
COUNTY WELL PERMIT #(f applicable) !
Bentonits '
DWQ or OTHER PERMIT#(if applicable) Bentonite lb.
WELL USE(Check applicable use)a Monitoring Cs Residential Typ;❑Slurry pellets
0 M unicipaliPublic ❑ IndustdaUCommerclat O Agricultural Water ®___r�____�9ai•
Ether
0 Recovery 0Injection 0 Irrigation
Type material
0 Other(list use)
Amount
3.WELL LOCATION:
COUNTY"Rom XdUADRANGIE NAME 9• EXPLAIN METHOD OF EMPLACEMENT OF MAJERtAL
NEAREST TOWN: 0.1 t 5t1.r L IJ�C
I
6
(StreeURoad Name,Number,Community,Subdivision,Lot NO.,Parcel,Zip Code)
TOPOGRAPHC t LAND SETTING:
0 Slope (=T Valley Cl Flat 0 RidgeO Other
: 10, WELL DIAGRAM:Draw a detailed sketch of ball on the back of this
(Check appropriate setting)
form showing total depth,.depth and diameter of screens(if any)remaining
S in the well,gravel intenial,intervals of casing perforations,and depths and
LATITUDE �86— _�»--� �-°mS OR 3X X types of fill mstert lwsed
LONGITUDE S--- DMS OR 7x• *O0 D
CltaPo9 P
ra hic map 91. DATE WELL ABANDONED
Latitudeliongitute source: 1)rfGPS
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) IVppHEREBY CCERCITHAT07HIS WijON STANDARDS,;AND THAT ANDONED IN DCOPY OF
4a.FACILITY-The name orthe business where the well is located.Complete 4a: : THIS REC RD S BEEN P� ID TO THE WELL OWNER.
(if a residental we11,skip 4a;complete 4b,well owner inromlallOn only.) _
FACILITY ID#(if applicable) DATE
SIGN T RE OF C TIFI WE C CTOR
NAME OF FACIUTY � P
STREET ADDRESS p
SIGNATURE OF PRNTEE WELI.OWNER A6ANX>ONING THE ttI M DATE
Zip Code (The private well owner must beanindM)uat rs°na rrdonstisiherresidentialwell
CilyorTown State inaccordancewith116AN A 2C'ot13
4b.CONTACT PERSONMIELL OWNER:
PRINTED NAME OE SflN ABANDONIN THE WE LL
NAMES v JCS Rd, 1.)S�Dur�
STREET ADDRESS I P Pa
Form GW30
Submit a COPY:to the owner anti`the original to Division.of_Vlfater Qua4ty.=InformaaIton Processing, Rev.5t10
9697 Mail Setyrce Center;Ra)eigh,NC M99107,'Phone:[phone] i.