Stanly_Well Abandonment_20240529 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
I.NNell("ontractor Infornialion: WELLABANDONMENT DETAILS
Brian James Bellis 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor\.tme(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 wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0_(gall.)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONI l:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.(/IC,County State.Variance,etc.)ifknown
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 s Neat Cement Grout _7 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay '�R.'
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings MAY y
❑Irri tion ❑ Specialty Grout ❑Gravel �G24
Non-Water Supply Well: ❑ Bentonite Slurry1
❑ Other(ext�'dD;Nfider.7p) -- •5, � _.,' �*fit
eMonitoring ❑Recovery ;
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation --25 lbs Of Grout
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well was already filled in with soil to ground level.
well head area, and top foot of casing was was dug out.
a.Date well(s)abandoned: 5/3/2024 casing 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) S.Cerlification:
1906 Badin Road, Albemarle, NC 28001 ��-5/14/2024
Physical Address,City,and Zip Signature of Certifi We Contractor or Well Owner Date
Stanly 655801360471
By signing this form, /hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0/00 or 1C.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.
(ifwell field,one lavlong is sufficient) 9.Site diagram or additional well details:
35.3566310 N -80.1640130 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)ifavatlable. h'ormultiple injection ornon-water.supplywells
ONLY with the same construction abandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: NA (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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
abandonment to the following:
6d.Water level below ground surface: NA (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): NA (ft.) 10c.For Water Sunoly&Iniection 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 known): NA (ft.) abandoned.
6g.Screen length(if known): NA (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016