Randolph_Well Abandonment_20240318 (2)

WELL ABANDONMENT RECORD For Internal Use ONI,Y
1.Well Contractor Information: WELL:IBANDONMENT 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 G W-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#: 2024-00000723
List all applicable hell consirrrclion permits(i.e.WC,County,.Slate,Variance,etc.i it known 8 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 Grout q S jTentoonite Chips or Pellets
❑Geothermal(1-leating/Cooling Supply) FlResidential Water Supply(single) ❑ Sand Cement Grout i V"L9ry 11
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout l ir+,if t g ��1❑,�Dri uttings
❑lrti gation ❑ Specialty Grot{li, O Q�Gravel
Non-Water Supply Well: ❑ Bentonite Slurry " ! .ra - ❑Other(explain under 7g)
❑Monitoring ❑Recovery e,'�e g
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Concrete grout 2 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
4.Date well(s)abandoned: 3/1 3/24
capped with 12"thick concrete plug.
52.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
5727 Julian Airport Rd. Liberty, NC 27298 '// r& 41 29�7 iq 3/13/24
Physical Address.City,and Zip Signature of Certified Well Contractor or Well Owner Date
Randolph 8708614323
Hy signing this Jorm, !hereby certify that the well(.t) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 01C.0100 or 2C.0200 Well Construction.Standards
and that a cony of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.895278 N 79.649444 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
Attach wellcom7racalinrecord(s)rjmvailahle. hilrmultiple injection ornon-uarersupplywells
ONLY with the.same constntction ahandonmeni,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: 185 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): N/A (ft.) IOc.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 GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016