Montgomery_Well Abandonment_20240401

WELL ABANDONMENT:RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
K. Brandon Moore fs
i 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally ab,,,:in well on his/her property) well construction/depth,only 1 GW I30�is needed. Indicate TOTAL NUMBER of
2957-A wells abandoned:
NC Well Contractor Certification Number P, 7b.Approximate volume of waterremaining in well(s): (gal.)
Paragon Environmental Consultants, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium Hypochlorite
eL 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,:'CGrmty,State,Variance,etc.)ifknown 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 ❑Mtmicipal/Public ❑Neat Cement 19%u� ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Rsldential Water Supply(single) ❑ S d Cement 7 Clay
_ 1 Cutti
ngssIndustrial/Commercial ❑Aidential Water Supply(shared) a Concrete Grout r
❑hri ation ❑Specialty Grout A f) 2Or4 ❑Gravel
Non-Water Supply__W.ell:___ k' ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery Asa
Injection Well: i 7f.For each material 430.tl �abo�e,pr 1ViWe%fitount of materials used:
❑Aquifer Recharge D, undwaterRemediation Concrete grout 3 cubic yards
❑Aquifer Storage and Recovery p�i�Barrier
k �•
❑Aquifer Test ❑ water Drainage
f
❑Experimental Technology ❑tSbstdence Control
p 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑3er
❑Geothermal(Heating/CoolingRetum l7 _ (explain under 7g) Poured concrete directly into well casing
r and filled to top of casing terminated below
a.Date well(s)abandoned: 3/25/24 k ( the land surface with' 12"thick concrete
5a.Well location: plug installed above the top of casing.
NC DOT ; "N/A
Facility/Owner Name Facility ID#(if applicable) S.Certification:
4561 NC Highway 24 ,/ 3/26/24
Physical Address,City,and Zip Signature of Certified Well Contract r or Well Owner Date
Mt. Gilead, NC 27306 J;7p
586 00 48 2522 By signing this form, I hereby cert�that the wells) was(were) abandoned in
County pA pA /f�� l Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
"' qo �� andthata copyofthis recordhas beenprovidedto the wellowner.
5b.Latitude and longitude in degrees/mu'unds or decimal degrees: ;
(ifwell field one]at/long is sufficient)
�1 9.Site diagram or additional well details:
35.307690 N 80.057$33 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)WING ABANDONED
SUBMITTAL INSTRUCTIONS
Attach ivell construction record(s)ifavailable.For '" "'lnjectianornon-water supplyrvells
ONLY with the same construction/abandonment,yottrstrbnut one form.
10a. For All Wells: Submit this form within 30 days of completion of well
SW-1 abandonment to the following:
6a.Well ID#: anonmen owg
Division of Water Resources,Information Processing Unit,
I,�. :ij;
6b.Total well depth: 220 ':( 1617 Mail Service Center,Raleigh,NC 27699-1617
5 10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (` 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: Un Wn (ft) Division of Water Resources,Underground Injection Control Program,
yy, �; 1636 Mail Service Center,Raleigh,NC 27699-1636
9
Unkn 10e.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): � (ft.)
l 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): own (ft.) abandoned.
i �
6g.Screen length(if known): Unknown I (ft)
Form GW-30 Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016