Wake_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well 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 1 GW-30 is needed. Indicate TOTAL NUMBER of
NCWC 3510-A wells abandoned:
NC Well Contractor Certification\wwber 7b.Approximate volume of water remaining in Nell(s): —454 (gal)
WithersRavenel, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HTH
2.Well Construction Permit#: Not Applicable
List all applicable well construction permits(i.e.l/lC,County,State,Variance,etc.)if known —1 4 ounces
7d.Amount of disinfectant used:_
3.Well use(check Nell use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chiis or Pellets
❑Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑ Drill Cuttings MAY v ;t 20A
❑lrri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(expldfn`ti Wier 7,.2)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Concrete Grout -65 cubic ft ("2.4 cy)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control �M
ProN ide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under7 ) Concrete grout mixed in a commercial cement mixer
was slowly poured into well until well was completely
a.Date well(s)abandoned: 5-15-2024 filled. Top three feet of well casing cut off and buried
5a.Well location: three feet below ground per Wake Cnty requirement.
Sundance of NC, LLC NA
Facility/Owner Name Facility ID#(if applicable) S.(ertitication:
1529 Salem Church Road, Apex 27523 -��5� 5-20-2024
Physical Address,City,and Zip Signature ofCerti d)A1 Contractor or Well Owner Date
Wake 0743818299
By signing this form. /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
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 9.Site diagram or additional well details:
35.759377 y -78.835231 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 records)ii"arailable. hor multiple injection or nor-water supply wells
ONLY with the same construction abandonment,you can submit one form.
10m. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 1529 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total Nell depth: 330 (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: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.NN ater level beloss ground surface: 20.78 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): Unknown (ft) 10c.For Water Supply&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 Innercasing/tubing length(if knossn): 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