Yadkin_Well Abandonment_20240617

, /'��VELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
I cc�C7Tx`� t 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or 4yell owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of G!-
wells abandoned: ..�
NC W'.i.Confrsctor Certification Number 7b.Approximate volume of water remaining in well(s): _(gal.)
YADKIN WELLCOMPANY INC. FOR WATER SUPPLY WELLS ONLY:
Company Naiite 7c.Type of disinfectant used: loC/� Ibr INS `�
2.1Weli Construction Permit N: WA Der%AM to, YC
List all applicable well construction pennits('.e.UIC. un%State,Variance,etc.)iflmonn
7d.Amount of disinfectant used:_
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used.(check all that apply):
❑Agricultural ❑M�unicipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) & esidential Water Supply(single) ❑ nd Cement Grout ❑ Dry Clay '
❑Industrial/Cotnm�iah ,'" stdential Water Supply(shared) L�l Concrete Grout ❑ Drill Cuttings
❑Irri ation = . +s' -,L—1 � + ❑ Specialty Grout - ❑ Gravel
Nori-\Voter Supply Well;,A' n .20�4 ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring J�JN / (]Recovery
i,tie..ctiott Well: r 7f.For each material selected above,provide amount of materials used:
.aquifer Recharlk&�"Ts N. un
❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g•Provide a brief description of the abandonment pro edure:
❑Ge4tlieftpl;.(.Closed'Loop) ❑Tracer
❑Gegttl., na(,(H taEin Cooling.Retum). ❑Other(explain under 7 ) Z,l
5 ate- 4A n —01 C� Ner a A lswo1
4.Date well(s)abandoned: 'A
ia.Well location:
ACC Loe ecr
Facility/Owner me Facility ID#(if applicable) 8,Certiftcat• .
Physical Address,City,and Zip, Signature o Certified ell or Ow er Date .�}
By signing this form, 1 tereby cent drat the wells) was (were) abandoned in 'F7"'
Couhty Parcel Identification No.(PIN) accordance with 15A•NCAC 01C-0100 or 1C.0100 Well Construction Standards
and that a copy of this record has been provided to the well owner-. o�
' SIi.,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar4ong is sufficient) 9.Site diagram or additional well details:
34.0CQI01 N -$QM)9 03Z1 W You may use the back of this page to provide additional well site details or well 0-
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailoble. Formultiple injection ornon-watersupplywel(s
QiVLYtiritlydte some constuctiwnlabondomnent,you can submit one form.
10a. For All Wells: Submit this form.vy0iR.�O?;days..of-completion of well
i" abandonment to the following:
Ga. g; ,. ..
Division of Water Reso.urcesi Information Processing Unit,
6b.Total well depth: 1617 Alai]Service Center,Raleigh,NC 27699-1617
10b.For Ioiectiou Wells:. In addition to sending the form to the address in 10a
6c.Borehole diameter: (iu.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: J
t `
Gd.;\\'ater Icvel below ground surface: T (tt.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6cy Outer casing length(if known); (ft.) 10c.For Water Supply&Injection Wells: In addition to sending the form to the
addresses)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
617;Inner casing/tubing length(if known): abandoned.
6g.-Screen length(if known): (ft.)
C.- NV-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016