Iredell_Well Abandonment_20240731 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr. 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
4532-B wells abandoned:
NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): —12 —(gal-)
Excel-SRP Environmental F It ,, �;���'"� FOR WATER SUPPLY WELLS ONLY:
Company Name JUL 3 Chlorination-CA(OCL)2
- 2024 7e.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits•(i.e. �ftgreAVoramce,eta)ifkaawn
Kfd9w • -11'4:`,41 ', p* 7d.Amount of disinfectant used: 6-OZ
3.Well use(check well use): dt.t:I,.-
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Mtrnicipal/Public a Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑hri+ation ❑SpecialtyGrout ❑Gravel
Non-Water Supply Well: ❑Bentortite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite-- 50 Ibs concrete--25 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Storrnwater Dminage neat cement^-20 Ibs
[]Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochlorite into well and filled
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7 )
casing with bentonite pellets and poured neat cement
4.Date well(s)abandoned: 7I2/2024 until a rox 2- I and pp tbg poured concrete inside casing
5a.Well location: to near TOC an on the manhole
Gordon Iron & Metal MO-3735
Facility/Owner Narne Facility IDk(if applicable) 8.Ce on:
1300 Salisbury Rd, Statesville, NC 28677
Physical Adcfress,City,and Zip Si Cenif W for o Well her Dot
Iredell 4744819411.000
By.signing dais forts, I hereby certify that the weU(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Conutruction Standards
and that a copy of this record has been provided to the well owner.
56.Latitude and longitude In degrees/minutes/seconds or det3mal degrees:
(if well field,one ladlong is sufficient)
9.Site diagram or additional well details:
35.773476 Y (-)80.858403 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 cowirucaan record(s)ifavailable.For multiple injection or not-wafer supply wells
ONLY with the same conctructionlat andonmem,hnu can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: RW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 40 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For Iaieetion Wells: in addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) 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: —23 (g) Division of Water Resources,Uodergro®d Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): na 10c.For Water Supply&Injection 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
61.Inner casing/tubing length(if known): na (ft.) abandoned.
6g.Screen length(if known): UNK (ft.)