Rowan_Well Abandonment_20240116

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' J `.t`'' , WELL-ABANDONMENT RECORD
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"' ' 14.. 7, North Carolina Department of Environment and Natural Resources-Division of Wa er Quality
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'��"" �y''" WELL CONTRACTOR CERTIFICATION# q 7toci C' -I
1.WELL C NTRACTOR: 6. WELL DETAILS: ,
AO k n n ii L a.n h I 1 •
a.Total Depth 41 ft. Diameter: in.
Well Contractor(Individual)Name 1 b.Water Level(Below Measuring Point): 31 ft.
1 o Li.So r �d.t t tJy I j k Ai Measuring point is t o r t '• #above land surface.
Well Contractor Company Name
4i',1-1-b Sherri 11s Ft r cC �'l� 6. CASING: : Length Diameter
Street Address Sal isbtArta.Casing Depth(if known): ft. in.
+' State Zip Code b.Casing Removed:
City or Town /�
(!}p ) (0 3 Ln m% 7. DISINFECTION: l�tl liRp t h t
Area code Phone number •
(Amount of 65%75%u calcium hypochlorite used)
2.WELL INFORMATION: ' r 8. SEALING MATERIAL:
SITE WELL ID# (if applicable)
5 -Neat ment - Sand Cement
STATE WELL PERMIT# (if applicable) Cement lb. Cement lb.
COUNTY WELL PERMIT #(if-applicable)
q 0 la(3 -3 Water gal. Water gal.
Bentonite
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DWQ or OTHER PERMIT#(if applicable)
Bentonite lb' , .,
WELL USE(Check applicable use)-0 MonitoringResidentfat Type;l]Slurry ellets • '- 6-.-hws A_i" ky Q..)
0 M unicipallPublic 0 Industrial/Commercial Cl Agricultural Water (.P ' gal. JA N 1 6 2024
0 Recovery 0 Injection 0 Irrigation Other
0 Other(list use) Type material v u l';Wi::,:'ll z
Amount 1 i
3.WELL LOCATION:
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COUNTY TO W QUADRANGLE NAME
NEAREST TOWN: R—(x-k4..e-il t ne- 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
2,2g5 •E yy,ima-In tile.1 (*h grA.
;11I 221 asc,) t
(StreetlRoad Name,Number,Community,Subdivision,Lot No.,Parcel,Zip Code)
TOPOGRAPHC I LAND SETTING: f
B Slope 0 Valley ❑Flat Cl Ridge0 Other -
(Check appropriate setting) 10. WELL DIAGRAM :Drawn detailed sketch of%tell on the back of this
•j fl form showing total depth;depth and diameter of screens(if any)remaining
LATITUDE S _3_' S -DM5 OR 3X.)D000000000 . in the well,gravel interval,Intervals of casing perforations,and depths and
LONGITUDE •
a MS OR 7X.)00000 XXIXD types of fill materialsised
Latitudeltongitu a sour . 'OGPS OropOgraphic map 11. DATE WELL ABANDONED
(location of well must be shown on a USGS topo map andattached to
this fonn if not using GPS) 100 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF
4a.FACILITY-The name of the business where the well is located.Complete 4a: THIS RECO D HAS BEEN PGVIDED TO THE WELL OWNER.
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(If a residential well,skip 4a;complete 4b,well owner information only.) r-7(
FACILITY ID#(if applicable) TUREOF ERT I WELL CONTRA TOR DATE
NAME OF FACILITY .
STREET ADDRESS
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wpersonallwbandons hisrher residential well
In accordance with 15A NC C 2C.0113.)
4b.CONTACT PERSONIWELL OWNER: " - hv)yl Y-}-Ir1 tn„r,el
NAME Pr e•-W Mahe- PRINT` D NAME OF RSON ABANDONING THR WELL . .
STREET ADDRESS 13D1 rnco r u III r`Q`(, lV.l;o ras v i Ile
SILOS I -
Submit a copy to the owner andtf a original to:.Divisionof Water Quality-Information Processing, Form GW-30
1617 Mail Service:Center,Raleigh,NC 27699-16.17,Phone:[phone]
f Rev.5/10

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS I
1,J1 C,T I Si VIDSCAO 7a.For Geoprobe/DPT or Closed-L lop Geothermal Wells having the same
Well Contractor Name(oell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4SZn `C wells abandoned: I i /� q
NC Well Contractor Certification Number n,,� 7b.Approximate volume of water r'niaining in well(s): 1 (gal.)
10 fo fi �iL\ N►' Y Q \tnC, FOR WATER SUPPLY WELLS ONLY: `
Company Na I p /►
3019101 I ^ 7c.Type of disinfectant used: Sr��1a�tf d li h �(J f6
2.Well Construction Permit#: (,j , 1 .�
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifbiounn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Grout Nentonite Chips or Pellets
['Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ['Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
[Monitoring ['Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
0 Aquifer Recharge ['Groundwater Remediation G QI
❑Aquifer Storage and Recovery ❑Salinity Barrier J
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ['Tracer l 1,, I f
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) F1`re13,.\ \ V)O� L U-` i
4.Date well(s)abandoned: ,a—l 1 ^a-a �Z�J� ' ,;,� y�� ,r 4 4 C
5a.Well location: JAN 1 6 2024
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Facility/Owner Name Facility ID#(if applicable) 8.Certificat' .. ,g(,,N3i
q 15a c.) (',hirt(Eravc,pc 0093 0 a 3
Physical Address,City,de.c1 Zip S' a of Certified Well Contractor or1 Well Owner Date
ecuon a.3(4 (26
By signing this form,I hereby cent fy'that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15,1 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 welldetails:
. 5'I 3 39 N tO.(12:1 L&(t,'1 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)if available.For multiple injection or non-water supply wells
ONLY with the same constructian/abaidonrnent,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: 3 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in l0a
6c.Borehole diameter: U (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: a 5 (ft.) Division of Water Resources,iUriderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): A- (ft.) 10c.For Water Supply&Iniecti
PIA- 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
6f.Inner casing/tubing length(if known): NA-/�►. (ft.) abandoned.
6g.Screen length(if known): O n (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2-22-2016
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