Stanly_Well Abandonment_20240710 (3)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABAND LAMENT DETAILS
Johnny W Hart Jr 7a.For Geoprobe!IDPT 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
4446 B wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 4O5 (gal.)
McCall FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: H
TH
2.Well Construction Permit q:4 1 2957-1
List all applicable well construction permits(i.e.U1C,County.State, Variance,etc.)f)known 9.5 oz
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay i
❑industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑ Drill Cuttings 1
❑itri ation ❑ Specialty Grout ❑Gravel I
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain andtjr 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquife#Recharge ❑Groundwater Remediation 3 yd s
❑Aquifer Storage and Recovery ❑Salinity Barrier 1
❑Aquifer Test ❑Stormwater Drainage _
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure: t
❑Geothemtal(Closed Loop) ❑Tracer Pour con rete into well until full
❑Geothermal(Heating/Cooling Rehm) ❑Other(explain under 7g)
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4.Date well 5/29/24 s)abandoned: AN
5a.Well location: U
NCDOT
Facility/Owner Name Facility fDk(it'applicablc)
8.Certification:
48201 NC 24E
Physical Address,City,and Zip Sig ore of Certi d Well Contractor or Well O er Date--
Stanly
By signing this form, /hereby certify that t e well(s) was (were) abandoned;+z
County Parcel Identification No.(?IN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standaras
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil field,one IaUlnng is sufficient) 9.Site diagram or additional well details:
35 18' 51" N 80 06' 00" W You may use the back of this page to provide additional well siteldetails or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS i
Attach well construction record(s)ifavailahle.. For multiple injection or non-water supply wells
ONLY with the.same construction/abandmnnent,you can.submit nne jornr.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well)D4: abandonment to the following:
I Division of Water Resources,Information Processing Unit,
6b.Totallwell depth: 300 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For injection Wells: In addition to sending the form to the Address in l0a
6c.Borehole diameter: 6 (in,) above, also submit One copy of this form within 30 days of completion of well
abandonment to theifollowing:
fid.Witter level below ground surface: 30 (ft.) Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6c.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): (ft.) abandoned.
fig.Screen length(if known): A)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016