Alamance_Well Abandonment_20240311 (8)

WELL ABANDONMENT RECORD For Internal Use ONLY: i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Rawlins E Clarke IV 7a.For Geoprobe/DPT or Closed LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW 1 30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS�ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: W10400614
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown
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 S Neat Cement Grout ❑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 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ®Groundwater Remediation 3-941bs bags
❑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
Three bags of 94 lbs neat cement grout tr"th_.watrr gpd tremie
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) � a''
�z. ,
grouted from bottom of bore hole to the top.
4.Date weil(s)abandoned: 2/27/2024 ;' M 1 1 20Z4
5a.Well location: 1,
Tarheel Army Missle Plant
Facility/Owner Name Facility ID#(if applicable) 8.rtion:
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 A F ' 02/28/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or1 Well Owner Date
i
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:
(if well field one lat/long is sufficient) 9.Site diagram or additional well details:
36.0993864 N -79AO92444 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 I; '
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit thisl'form within 30 days of completion of well
6a.Well ID#:
IP-N.06 abandonment to the following:
Division of Water Resour les,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service CenlIter,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
6e.Borehole diameter: (in.)
abandonment to the following: f j
6d.Water level below ground surface: 20 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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
NA abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016