Alamance_Well Abandonment_20240507

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WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS •
J. Michael Venable 7a.For Geoprobe/DPT or ClosedfLoop 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
NCWC-2079-A wells abandoned:
1,000
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Venable Brothers Well Const., Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name Calcium H YPpochiorite
7c.Type of disinfectant used:
2.Well Construction Permit#: ,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflarown 30 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 0 Neat Cement Grout 0 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) 0 Sand Cement Grout II Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) P Concrete Grout 0 Drill Cuttings
❑Irrigation 0 Specialty Grout 0 Gravel
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery •
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation well mix- 18 yards
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage clean clay-1 yard
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) OTracer
❑Geothermal(Heating/Cooling Return) ❑other.(explainlmdcc 20"well at top; unknown diameter at bottom;
a :::.v� .4/a i. +r` ?...�.removed plumbing; dewatered; chlorinated;
4.Date well(s)abandoned: 2/16/24 -
MAY 0 i 2024 removed top 3 ft of tile; filled with
5a.Well location: well mix to form lu to ed with clean clay
GREEN LEVEL MHP ►r„�z;• a.4C �c %� .,F�Urk p g,,, pp
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
2156 JAMES BOSWELL RD., BURLINGTON, NC 2/19/24 -
Physical Address,City,and Zip Signatu of Certified Well Contractor or Well Owner Date
ALAMANCE 8896338641
By signing this form,I hereby cert5 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
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 lat/long is sufficient) 9.Site diagram or additional well details:
36.12123 N -79.35766 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)ifavailable.For stiultipie injection ornon-watersupply we/Is
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
6a.Well ID#: abandonment to the following:
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Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (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: 20 /unknown(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
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6d.Water level below ground surface: 32 (ft) Division of Water Resources',Underground Injection Control Program, t
1636 Mail ServiceICenter,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 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): (ft.) abandoned. _
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6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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