Stanly_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.M ell Contractor Information: WELL ABANDONMENT DETAILS
Brian James Bellis 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 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wel Is abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): ~3'4 (gal.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:_
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Suppy %%ell: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public N Neat Cement Grout ■ Bentonite Ch ps of Nilels.'.r i.11
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout Dry Clay ��AY .)
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings 2024
Dirrigation ❑ Specialty Grout ❑Gravellt'
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain ur6erfg)t,.•:�
S Monitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation —28lbs Bentonite
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ^61bs of Grout
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Bentonite was placed in one foot lifts and hydrated
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
until one foot from top of casings. Remaining space
a.Date well(s)abandoned: 5/3/2024 was capped with grout to surface grade, flush
5a.Well location: mount protective cover filled with grout.
C.K.EARNHARDT AND SON INC 00-0-0000008903
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
1906 Badin Road, Albemarle, NC 28001 5/14/2024
Physical Address,City,and Zip Signature ofCerti ed ell Contractor or Well Owner Date
Stanly 655801360471 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.
(if well field.one lat/long is sufficient) 9.Site diagram or additional well details:
35.3566310 -80.1640130 N 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 OFWELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ijavailable. For multipir ugection or nun it Oversupply wells
ONLY with the same construction abandonment,you can submit one Jorm.
10s. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: DW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 26.00 (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: 2(inner)6(outer)(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: 5.80 (ft.) Division of Water Resources,I nderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 - 19 (ft.) 10c.For Water Suooly&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
6E Inner casing/tubing length(if know it): 0 - 21 (ft.) abandoned.
6g.Screen length(if known): 21 - 26 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016