Union_Well Abandonment_20240325 (2)

WELL ABANDONMENT RECORD For rntema,Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL AMNDONMENT DETAILS'
John W. Huneycutt . ;_ 7a.Number of wells being abandoned:! 1 ~
Well Contractor Name(or well owner lcrsonaUy abandoning well on his/her property) For multiple injection or non-waler-'•supply ivells ONLY- with the same
. conslruction/abandonmem,you can submit one form.
2465-A :: .
' 322.5
NC Well Contractor Certification Number7b.Approximate volume of water remaining in well(s):
I,
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
_ - ' Granular
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#!;
20-555. . .,
List all applicable well permits(i.e.County,State,Variance,Injection e[c.J iflmown 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(ch`eck well use):
Water Supply Well: a 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 1l Bentonite Chips or Pellets
pGeothermal(Heating/Cooling Supply) OResidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑IndustriaUCommercial []Residential Water Supply(shared)• ❑Concrete Grout ❑Drill Cuttings
oln-igaidon ❑'Specialty Grout ❑Gravel
Non-Water Supply Well: 123 Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑GroundwaterRemediation 500,lbs':-Bentonite Slurry.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test QStormwaterDrainage 100 Ibs- Bentonite Chips
❑Experimental Technology []Subsidence Control 7g:Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well was pumped with;bentonite slurry through
❑Geothermal(Heating/Cooling Return) QOther(explain under 7g)
a 1"tremie pipe extending down into well up to-3'
a.Datewell(s)abandoned: 11/29/23 below surface. Remainirig'S"Was gravity fill e-d
5a.Well location: with bentonite chips.
Matthew&Megan Kimball j
I
Facility/Owner Name Facility D34(ifappticablc) 8.Certification:
5512 Cane Creek Rd., Waxhaw 28173 Qa& G!J Yr 12/14/23
Physical Address,City,and Zip Signa6dic of Certified Well Contractor m6Vell Owner Date
Union 05027001 G By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Constniction Standards
and that a copy of this record has be i n 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:
You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach ivell construction record(s)if available. For multiple injection or non-water supply
wells 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
P. I,� �7 iib andonment to the following:
6a.Well ID# c A�•�C,�i:- i
A r� Division of Water Resources,Information Processing Unit,
245 MA R 2 LU74 1617 Mail Service Center,Raleigh,NC 276994617
6b.Total well depth: (ft.) i
!ft'i;�iY=s,'^Tt fir-=`a„c4u ( g ab.For Iniection Wells: In addition'to sending the form to the address in 10a
6 Gu:e/ !i, above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following: '
Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: 30 (ft.) 1636 Mail Service Center,Raleigh;NC 27699-1636
60 10c.For Water Suoaly&Infection.Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6E Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

# 9—Well Diagram V Well Diameter
1 No PVC Casing
Removed
0' to 3' Filled with
............ Bentonite Chips
Casing Depth: 60' ,,
T to 245' Pumped
with Bentonite
245'—Total Well Depth