Randolph_Well Abandonment_20240318

WELL ABANDONMENT RECORD For Internal Use ONLY
1.Well Contractor Information: W'EI,L ABANDONMENT DETAILS
K. Brandon Moore 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 I GW-30 is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH Chlorine
7c.Type of disinfectant used:
2.Well Construction Permit#: 2024-00000722
List all applicable well construciten permits(i.e.UK;County,State,Variance,etc.j ij'known 1 3 oz
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 ❑ Neat Cement Groat- ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement dr6uL �' ,r L ry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) e Concrete Grout ,qt �d rill Cuttings
❑Irri gation ❑ Specialty GroutMHN 8 2014 ❑Gravel
Non-Water Supply Well: ❑ Bentonmku ❑Other(explain under 7g)
❑Monitoring ❑Recovery 1`D�'�:. r.
Injection Well: 7f.For each materJ14Rhi J e,p ovide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 3.5 cubic yards
❑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 Poured concrete directly into well and filled to top
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
of casing terminated below land surface and
a.Date well(s)abandoned: 3/13/24 capped with 12"thick concrete plug.
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
6041 Starmount Rd. Liberty, NC 27298 &2i # 295-1-4 3/13/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph 8717335231
By signing This form, 1 hereby cerliJy that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with/JA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 9.Site diagram or additional well details:
35.873056 N 79.630278 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
Attachwellconsiniclionrecords)iJ'ai,ailable. hiirmuluple injection ornon-watersupplywells
ONLY with the.same c•anstnichon abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: SW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 380 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: N/A (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 42 (ft.) 1 Oc.For Water Suonly&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): N/A (ft.) abandoned.
6g.Screen length(if known): N/A (ft.)
Form G W-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016