Alamance_Well Abandonment_20240311 (10)

WELL ABANDONMENT RECORD For Internal Use ONLY..
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Rawlins E Clarke IV 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
wells abandoned:
NCWC 4234-A
NC Well Contractor Certification Number 7b.Approximate volume of water1
riimaining in well(s): (gal.)
Clarke Generations Drilling LLC FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit M W 10400614
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
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 a 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 3-94lbs 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 , '1
Three bags of 94 Ibs neat'cement grout mix with water and tremie
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
grouted from bottom of bore hole to the top. "'
4.Date well 2/21/2024s)abandoned: ; MAN I
5a.Well location:
Tarheel Army Missle Plant
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
204 N.Graham-Hopedale Rd.,Burlington,NC 27217 02/28/2024
Physical Address,City,and Zip Signature of Ce died Well Contractor or Well Owner Date
Alamance
By signing this form, I hereby certify that the wells) 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:
36.0989301 N -79.4086986 �V 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
Attach well construction record(s)ifavailable.Formultiple injection ornon-watersupply wells
ONLYwith 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-N.07 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 45 (ft.) 1617 Mail Service Centel r,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition'to sending the form to the address in 10a
6c.Borehole diameter: 4.5 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 20 (ft.) Division of Water Resources,Undlerground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
45 10c.For Water Supply&Injection 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
NA abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): NA
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016