Yadkin_Well Abandonment_20240529

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
PC A.0"', W Ir l cox 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
\'all 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
6-3. wells abandoned:
�
NC 1Veli,,Contiac{or Certification Number 7b.Approximate volume ofwater retrial ning.in well(s): dsa (gal.)
'YADKI°N WELL COMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Companiy'Nante
7c.Type of disinfectant used:
2.Well Construction Permit#:-1r A
List all applicable hell construction pernnits(i.e.UIC,County,State.Variance,etc)lbnown .{�
3.Well use(check well use): 7d.Amount of disinfectant used:_- O
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Gieothermal(Heating/Cooling Supply) ;Afsidentiai Water Supply(single) ❑ Sand Cement Grout la Dry-Clay
❑Industrial/Commercial i
❑Residential Water Supply(shared) oncrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout - / '9 h�0
P ty i�t�, v ayel
Nod-Water Supply Well: L?V entonite Slurry ❑Other(explain under 7g)
❑1vlonitoring ❑Recovery
.nir..ction Well: 7f.For each material selected Above,provide amount of materials used:
Lrquifer Recharge ❑Groundwater Remediation ^ t�
❑Aquifer Storage and Recovery ❑Salinity Barrier 1.��mmoC 1p7 "Wbp
❑Aquifer Test ❑Stormwater Drainage tro4
16 e,� s k.trf r
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geatl eirp�l;.(filosed'Lopp) ❑Tracer
❑Geothgrm 1,Ileating/Cooling Retum)_ ❑Other(explain under 7 �Cet�i�► U A �- t P
^�^aoa �e� �,a Q� �hU^betC J 1Vf�t.1 o ToP c�; OAF
4:Datervc11(s)abandoned: CONGre+ e P�
kAfflr,
Welllecation:
. C4 rr
Facility/Owner Name Facility IDr<(ifapplicable) 8.Certification;
a 3 3_� k-1,S tw y 6o 'nyi lle
Physical Address,City,and Zip. ,t^ 1� Signature of Ccni ed Well Contractor or Well Owner Date
By signing this fonn, I hereby certify that the ivelf(s) ivas (were)abandoned to
Coutnry Parcel Identification No.(PIN) . accordance with 15A•NCAC 01C-.0100 or 1C.0200 Well Construction Standards
' and that a copy of this record has been provided to the well owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if yell field,one IadQlong is sufficient) I- Q R 9.Site diagram or additional well details:
O� 11 �, 1 I N �0�l0 O�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
Arroc/ravel/con n stra,ctiorecord(s)ifovoilable. For multiple injection or non-water supply wells
QNLY with the same constntctiarniabandonment,you can submit ore form.
10a. For All Wells: •Submit this forrri.vri#hip.,NL dpys:of•completion of well
6a.�Vcil" bi:<'i abandonment to the following:
_`' 1 Division of Water Reso.orcesi Information Processing Unit,
6b.Total iv eIi-depth: (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
Ilk
10b.For Iniection Wells:. In addition to sending the form to the address in 10a
6c.Borehole diameter: (in,) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:.
L ,
6d.)Vater•level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
bey Outer casing length(if known): i— (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the foot to the
addresses)above,also submit one copy of this form Mthin 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.
6g.-Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016