Haywood_Well Abandonment_20240205

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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'3!is needed. Indicate TOTAL NUMBER of
4237
wells abandoned:4(2ttlr mlS f0m)
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2 (gal.)
W Walker Environmental Services, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0100547
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:;
i.
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check±all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout I e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
-- Non-Water Supply Well: -_ — _ - — -❑ Bentonite Slurry— ❑ Other(explain under 7
RMonitoring ❑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:
PDG-Canton,North CamlinalJoseph D.Baxley(The Bmadmy Group) I
I;
Facility/Owner Name Facility ID#(if applicable) S.Certification: William
)lam
3526 Pisgah Drive, Canton, North Carolina 28716 Walker. 1 "" 1/17/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Haywood 8645-87-1554 By signing this form, I hereby ceIrtify that the ivell(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C 1.0100 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 well details:
350 29' 41" N 820 52' 14" 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
Atlach well construction record(s)rfavailable. For multiple injection ornon-watersupply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• TMW-1 - TMW-2 abandonment to the following: ;,
_ -.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
ZOZ4 ,.
lOb.For Infection Wells: In addition to sending the form to the address in IOa
6c.Borehole diameter:
3 (in.) �r�,; ,r;r s�L bldve, also submit one copy of ihis form within 30 days of completion of well
tn`�r,lt y 4.l i
abandonment to the following:
16.5 Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: (ft.) I.
1636 Mail Service Center,Raleigh,NC 27699-1636
NA 10c.For Water Supply&Injecti I on 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
6f.Inner casing/tubing length(if known)- NA (ft) abandoned.
6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016