Rowan_Well Abandonment_20240507

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS;
Der L. un cu
Derry L He ff y 7a.Number of wells being abandon)d 1 ,
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with -the- same
cmulruclion/abandonment,you can submit one form
7b.Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
Derry's Well Drilling, Inc. FOR WATER;SUPPLY WELLS ONLY:
Company Name 7o-Type of disinfectant used: Granular
2.Well Construction`Permit-#c:395233-3.
List all appl/cahlewell permits(1.e.County',State,Variance,"Injecdon,e1c.)ifknown -1/2 lb.---
±, 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.SeaHfig:_materials used(check at1 that apply)-,
❑Agricultural ❑Municipal/Public ❑Neat Cement,Grout 0 Bentonite Chips or Pellets
[]Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) 0 Sand Cerant Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑'Specialty Grout r ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 25-ft--Bentonite Chlps'.
❑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 Well was gravity filled with bentonite chips from
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
top to bottom.
4.Date well(s)abandoned: 1/24/24 t g,•'
4+d. •4s i
5a.Well location: MAY 0 'i 224
Rhonda Robinson
Facility/Owner Name Facility IDN(ifapplicable) 8.Certification: ^[:y �� `t �Q
V� �•
200 Old Camp Rd., Salisbury 28147 pa2�*,L.. �C 1VCN5/24
Physical Address,City,and Zip Signature ofo6rtified Well Contractor ell Owner Date
Rowan 472040 By signing this form,I hereby cetrify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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:
(ifwell field,one Wong is sufficient) 9.Site diagram or additional well details:
k You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifm,ailable. For multiple injection or non-water supply i.
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
6a Well IDIl: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 10 00 1617 Mail Service Center,Raleigh,NC 276994617
10b.For Iniectton Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2 above,also submit one copy of this form within 30 days of completion of well
(in.) abandonment to the following: 1
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N/A Division of Water Resources;Underground Injection Control Program,
6d.Water level below ground surface: 00 1636 Mail Service Center,Raleigh,NC 27699-1636
1
10a For Water Supply&Infection Wells: In addition to sending the form to
6e.Outer casing length(if known): (f) 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. i'
6E Inner casingitubing length(if known): (IL)
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water R lurces Revised August 2013
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# 9—Well Diagram ?",Well Diameter
No Casing
Removed
♦ 0' to 10'filled with
Casing Depth Bentonite Chips
Unknown
10' —Total Well Depth