Haywood_Well Abandonment_20240205 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAIL'S
William Walker 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
4237 wells abandoned:4(2 for this f0m)
NC Well Contractor Certification Number 7b.Approximate volume of orate;remaining in well(s): 2 (gal.)
W Walker Environmental Services, LLC FOR WATER SUPPLY WELLS ONLY:
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Company Name
2.Well Construction Permit#:
WM0100547 7c.Type of disinfectant used:
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
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3.Well use(check well use):
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Well: 7e.Sealing materials used(check,all that apply):
❑Municipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets
Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
mmercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑ Specialty Grout ❑ Gravel
Non-Water Supply Well:-_- _ ❑ Bentonite Slurry - - ❑ Other(explain under 7g) -
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Approximately 1 bag per well
❑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 Abandoned the Temporary Monitoring Wells by removing well
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
materials and filling borings with bentonite chips/pellets.
4.Date well(s)abandoned: 6/20/23
5a.Well location:
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PDG-Canton,North Carolma/Aoseph D.Baxley(The Broadway Group)
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Facility/Owner Name Facility lD#(if applicable) S.Certification: William o=wn-w,U,,
weter.w-w,n.,.
3526 Pisgah Drive, Canton, North Carolina 28716 Walker` : :,,;:, a 1/17/24
1.Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
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Haywood 8645-87-1554 By signing this form, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0,100 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:
350 29' 41" N 820 52' 14" �/ You may use the back of this page to provide additional well site details or well
4 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction recor•d(s)ifavailable. For multiple injection ornon-watersuupplywells
ONLY with the same consuuction%abandonrnent,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TM W-3 - TM W-4 abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft) a.'�.yam"L "i, �� " 1617 Mail Service Center,Raleigh,NC 27699-1617
E'CD 5 2024 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 3 (in.) above, also submit one copy of this form within 30 days of completion of well
n 1; andonment to the following'
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1 7.0 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft) 10c.For Water Supply&Inieetion 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): NA (ft.) abandoned.
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6g.Screen length(if known): 10 (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016