Lee_Well Abandonment_20240401 (2)

y WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Joshua Green 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 GWJ36 is needed. Indicate TOTAL NUMBER of
4468-C wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): (gal.)
Charles R. Underwood Inc. FOR WATER SUPPLY WELLS,ONLY:
Company Name
7c.Type of disinfectant used: HTH
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used: 3 OZ
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) RResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑htdustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑bri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Neat Cement 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Disinfected well with HTM, no water remaining in well,
terminated casing 3-feet below grade, abandoned well
4.Date well(s)abandoned: 3/14/24 with cement grout entire depth and 6-inches above top.
5a.Well location: '�.
Lee County Government i. `��7 a
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: APR R 0 1 2OZ4�
1248 Broadway Rd, Sanford, 27332 _3/21/24
Physical Address,City,and Zip Signaiye of Certified Wel ontractor or Well Own,^ Q_ �5cwr' u A
ft
Lee
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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.459401 N -79.123313 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 well construction record(s)(available.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 19 (ft.) 1617 Mail Service,Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 24 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I
0 Division of Water Resources;,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service,Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Infection Wells: In addition to sending the form to the
address(es)above,also submit orie copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016