Union_Well Abandonment_20231215

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Howard L Rushing 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-;vater supply wells ONLY with the same
construction/abandonment,you can submit one form.
3342-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Carolina Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: 70%HTH Chl,6rine� .
�:.
23-303
2.Well Construction Permit#:
List all applicable well permits(.e.County,State,Variance,Injection,etc)iflatown 7d.Amount of disinfectant used: 15 oz Q�(' I
3.Well use(check well use): "+3:.rv., "]
7e.Scaling materials used check all that apply):
Water Supply Well: g (
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout R Bentonite Chips or-PelI
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
1Rlrri ation ❑ 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:
❑Aquifer Recharge ❑Groundwater Remediation ( 107)501b Bags
❑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 Removed Pump.Chlorinated well.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
Completely filled with bentbnite.
4.Date well(s)abandoned: 1 1/0 112023 Terminated Casing
5a.Well location:
Mario McKenzie
Facility/Owner Name Facility ID#(ifapplicable) S.Certification:
8101 Skye Knoll Drive Waxhaw, NC 28173 Ncwar]L Rashln,7r. 11/01/2023
Physical Address,City,and Zip Signature of Certi ed Well Contractor or Well Owner Date
Union 06-102-200 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
34.59.440 80.43.430 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
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 Re sources,Information Processing Unit,
6b.Total well,depth: 440 (ft.) 1617 MaII Service,,Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
be.Borehole diameter: 6 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
bd.Water level below ground surface: 35 (fit) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service;Center,Raleigh,NC 27699-1636
be.Outer casing length(if known): 39 (ft.) 10c.For Water Sunaly&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
bL Inner casing/tubing length(if known): N/A where abandoned.
bg.Screen length(if known): N/A
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
i .