Union_Well Abandonment_20240429

WELL ABANDONMENT RECORD For Internal Use ONLY: �
1.Well Contractor Information: WELL.ABANDONMENT DETAILS
K. Brandon Moore 7a.For Geoprobe/DPT or Closed-Loop op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 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 0NLY:
Company Name Calcium H ochlorite
7c.Type of disinfectant used: yp
2.Well Construction Permit#: Union Co. permit#24-122
List all applicable well construction permits(i.e.I1IC,County,.State,{variance,eta)ifknown 1i0 oz.
_ 7d.Amount of disinfectant used: I
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all'that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) [I Sand Cement Grout A Dry Clay
❑Industrial/Commercial ❑Residential Water.SpppJy,(st(are� ._ Z Concrete Grout i ❑Drill Cuttings
❑Irrigation ' pecialry Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
[]Monitoring ❑Recovery APR 2 5 2OZ4
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groui water-•�etrtedi49on^�a�a<,11t, ncrete grout 2 cubic yards
I il...�
❑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 Filled well length completely with concrete and
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 7g)
installed an 18"thick.concrete plug on top
4.Date well(s)abandoned: 4/18/24
I
5a.Well location:
NC DOT N/A
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
4001 Old Monroe Road
. 4-18-24
Physical Address,City,and Zip Signature of Cenified Well Contrhctor or Well Owner Date
Indian Trail, NC 28079 07-114-040 By signing this Jbnn, I hereby certify that the well(s) was (were) abandoned in
CountyO/17 Parcel Identification No.(PIN) accordance with 15A NCAC:02C.0100 or 2C.0200 Well Construction Standards
Y and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 9.Site diagram or additional well details:
35.073104 N 80.682869 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
Allach ii,ell cmzs7nielion recoril(s)ijavailable.l'or multiple b jection or non-[rater supply wells
ONLY with the same constnictimt!abmulottnieat,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: 50 (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: 4 (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: Unknown (ft.) Division of water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
N/A 10c.For Water Supply&Iniection Wells: In.addition to sending the form to the
6e Outer casing length(if known): (ft.) 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
6E 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

1
WELL ABANDONMENT RECORD For lntemalUse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
n o 1 1 Sr Oq 7a.Number of wells being abandon Id:'
Well Contractor Name(or well o%Iffer personally abandoning well on his/her property) For multiple injection or non-tivatgr supply wells ONLY with the some
construction/abandonment,you can submit pne form. �Jl
7b.Approximate volume of water remaining in well(s): (gal•)
NC Well Contractor Certification Number
M L V 1v` S wow
Ujl�. FOR WATER SUPPLY WELLS ONLY:
Company Name a 7c.Type of disinfectant used: 1 N-W
2.Well Construction Permit#: �Z
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)if known 7d.Amount of disinfectant used: 11�
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all'tbat apply):
blic ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑Agricultural ❑Munici
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
U, concrete Grout ❑Drill Cuttings
❑Industrial/Commercial ❑Residential Water Supply(shared) +
Cl Specialty Grout ❑Gravel
❑kri anon
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
[]Monitoring ❑Recovery
7E For each material selected above,provide amount of materials used:
Injection Well:
[]Aquifer Recharge CI Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of We abandonment procedure:
❑Geothermal(Closed Loop) ❑TracerX�1.2�( 3
vim✓ rn.fCe�! tr �i!/.te�
!]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned:.
5a.Well location: r 7
�i2✓o� <<N Cby+^ pCeficatiAPR 2 9 LGL4
Facility/Owner NaameeFacility M9(iiffapplllicaable)
,'Jri1* h ey V
Physical Address,City,and Zip o rtified W o ctororWellOwner` Dale
tn �, . 1ng this hereby certify that the tvell(s)was(were)abandoned in
County Parce dertification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatilong is sufficient) 9.Site diagram or additional well details:
� up, You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-crater supply
wells ONLY with fire same construction/abandonment,you can submit one form. 10a. For All Wells Submit this form within 30 days of completion of well
abandonment to the following:
6a.Well ID#:
Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: Zed (ft)
10b.For Iniection Wells: In addition to sending the form to the address in 10a
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: Z —(it) 1636 Mail Service Ceinter,Raleigh,NC 27699-1636
10c.For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): 7 y (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
where abandoned.
6f.Inner casing/tubing length(if known): (ft)
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department ofEnviroument and Natural Resources—Division of Water Resources Revised August 2013