Alamance_Well Abandonment_20240311

WELL ABANDONMENT RECORD For Internal Use ONLY:
II
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke N
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/deptb,only 1 GW-*is needed. Indicate TOTAL NUMBER of
wells abandoned: i
NCWC 4234-A
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): (gal.)
Clarke Generations Drilling I.LC FOR WATER SUPPLY WELLS ONLY:
Company Name I I'
7c.Type of disinfectant used: I I
W10400614
2.Well Construction Permit#: I`
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: �
3.Well use(check well use): i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ®Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothemtal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
Oh-rijzation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery i
Injection Well: 7f.For each material selected abovei provide amount of materials used:
❑Aquifer Recharge ®Groundwater Remediation 3-94lbs bags I
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test- ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control I'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1' 1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Three bags of 941bs neat cement grout mix with water and tremie
grouted from bottom of bore hole to the top.
w-® ice.f T R •1
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4.Date well(s)abandoned: 2/26/2024 �
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5a.Well location: MAK i ! 2024
Tarheel Army Missle Plant
Facility/Owner Name Facility ID#(if applicable)
8.Certification: hrfic�I7 t Pm,-W.a;f U?W
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 �, 02/29/2024
Physical Address,City,and Zip Signature of C rtified Well Contractor orjtell Owner Date
Alamance 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.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: i'
(if well field,one lat/long is sufficient) r
9.Site diagram or additional well;details:
36.0987356 N -79AO90456 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 SUBMMAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-watersupply 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#: IP-S.03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
45 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) �•
abandonment to the following:
_ I, I,
20 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) I,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): 45 (ft) 10c.For Water Supply&Iniection 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.
I .
6g.Screen length(if known): NA
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016