Moore_Well Abandonment_20240116

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Jason W. Pendley la.For Geoprobe/DPT or Closl d-Loop Geothermal Wells having the same '
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4360A wells abandoned: II
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
American Environmental Drilling, Inc. FOR WATER SUPPLY WELLS ONLY.
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Company Name lc.Type of disinfectant used:!HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.U/C County,State,Variance,etc.)ifknown I . 10
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 ❑Neat Cement Grout it Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout s Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection-Well:- — -— -— - - - 7£For each material-selected-ubovefprovide amount of materials used:--— -
❑Aquifer Recharge ❑Groundwater-Remediation Bentonite Chips 150 lbs.
❑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 Well borehole filled With cuttings overreamed with
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
augers to 20 feet and.filled with bentonite chips.
4.Date well(s)abandoned: 12-20-2023
5a Well location: ; r" �"°Lt
Ken Bass `iv 1 6 [024
Facility/Owner Name (if applicable) 8.Ce 'rcation:
1030 Chicken Plant Road Aberdeen, NC 28315 �l�''' '�r,;'°�`' r�"`1'L-22-2023
Physical Address,City,and Zip goature of Certified Well Contractor or Well Owner Date
Moore
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 latilong is sufficient) 9.Site diagram or additional well details:
35.19637 N 79.53104 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.
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—GON&T-RUC-TION-DETAILS OF-WELL(S)BEING ABAND _ _SUBMITTAL INSTRUCTIONS--- ——
Attachwell construction record(s)ifavailable.Formultiple injection ornon-watersapplywells
ONLYwith the same construction/abandonment,you can submit one farm. 10a. For All Wells Submit;this form within 30 days of completion of well
6a.Well D)ft: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total well depth: 95 (ft) 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter. 8 (m) 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: 35 (fk) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
95 10c.For Water Snnoly&Infection Wells: In addition to sending the form to the
6e Outer casing length(if known): (ft) 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
6£Inner casing/tubing length(if known): (ft,) abandoned.
6g.Screen length(if known): 40 00
Form GW-30 North Carolina Department of Environmental Quality-Division of Wafer Resources Revised 2-22-2016