Moore_Well Abandonment_20240119

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Green 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
4468-C wells abandoned: I 1
NC Well Contractor Certification Number 7b.Approximate volume of water;remaining in well(s): 21 0 (gal.)
Charles R. Underwood Inc. FOR WATER SUPPLY WELLS ONLY:
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Company Name HTH
7c.Type of disinfectant used:
2.Well Construction Permit#:
' List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 90z
7d.Amount of disinfectant used:
3.Well use(check well use):
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Water Supply Well: 7e.Sealing materials used(check!all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout ; 0 Bentonite Chips or Pellets
❑Geothermal(Heatin�/-- g,,CoolinuppJ.y),_ IReflential Water Supply(single) 0 Sand Cement Grout 0 Dry Clay
❑Industrial/Commer&ial t i i,L.--y,v I Rtsldential Water Supply(shared) El Concrete Grout ❑Drill Cuttings
❑Irrigation �i ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:JAN Y 91024 CI Bentonite Slurry El Other(explain under 7g)
❑Monitoring ❑Re cAvs.Thr ;
Injection Well: L. 7f.For each material selected above,provide amount of materials used:
['Aquifer Recharge U:"C" "' GroundwaterRemediation Neat Cement Grout j, 5 yards
['Aquifer Storage and Recovery ❑Salinity Barrier I1
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of.the abandonment procedure:
['Geothermal(Closed Loop) OTracer
Removed top 3-feet of well tile, installed pump to remove
['Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
remaining water from well.,After water was removed it was filled
4.Date well(s)abandoned: 12/21/23 to the top with cement grout including the surrounding excavation
5a.Well location: area where the tile was removed.
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Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1487 Rays Bridge Rd, Whispering Pines, 28327 a/.ua-� er. 1/9/24
Physical Address,City,and Zip Signal of Certified Well ontractor 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 15A NCAC 02C 10100 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 well details:
34.15.55 N -79.24.17 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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CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable. For multiple injection or non-water supply wells - i
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,
1617 Mail Service;Center,Raleigh,NC 27699-1617
6b.Total well depth: 42.5 (ft)
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10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 20 (in) above, also submit one copy of Phis form within 30 days of completion of well
abandonment to the following: G I
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6d.Water level below ground surface: 29.7 (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniectioi 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016