Iredell_Well Abandonment_20240731 (6)

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 Connector Certification Number F :,,�,t .i$V E L,j Th.Approximate volume of water remaining to weli(s):
Excel-SRP Environmental I II Q i ! FOR WATER SUPPLY WELLS ONLY:
Company Name 17�—��T-
7c.Type of disinfectant used: Chlorination-CA(OCL)2
2.Well Construction Permit#: ifiSCF `'' 71.r'ryy6 '7) Ufa
List all applicable well construction permits(i.e.U1C,Counnty, j K , Ic.)iitknown
?d.Amount of disinfectant used: 3-oZ
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑lrri gation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundWatetRemedMon Bentonite--25 Ibs concrete-- 15 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage neat cement_ 10 Ibs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochlorite into well and filled
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
casing with bentonite pellets and poured neat cement
a.Doh well(s)abandoned: 7/2/2024 until approx 2-fbgl and poured concrete inside casing
5a.Well location: to near TOC and pia the manhole
Gordon Iron & Metal MO-3735
Facility/Owner Narne Facility ID#(ifawticable) 6d lion:
1300 Salisbury Rd, Statesville, NC 28677 y I gblf
Physical Address,City,and Zip Sr tune of C � Well Con or Well Iredell 4744819411.000By signing thisform,1 hereby certify that the well(s) wastee)abandon in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/secends or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one latilong is sufficient)
9.Site dugram or additional well def>tts:
35.773476 N (-)80.858403 W You may use the bads of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCPION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
.itiachwalleon,%iruciionrecord(s)ifavailable. For muliiple Injection or non-water srgrylywells
ONLY with the.came construction/abandonment,you can submit oneform.
102. For All Wells: Submit this form within 30 days of completion of well
6a.Well HW: MRW-9 abandonment to the following:
Division of Water Resources,inforutation Processing Unit,
6b.Total well depth: 40 (R-) 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
10b.For iniection Wells: In addition to sending the fore to the address in 10a
6c.Borehole diameter: 2 (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: —21 (ft) Division of Water ReseurcM Uudergroutad Injection Control Program,
16M Mal Service Center,Raleigh,NC 2769961636
6e.Outer casing length(if known): na VL) 10c.For Water Supply&lniection Wells: In addition to sending the form to die
addmss(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
6f.Inner casingttubing length(if known): na (ft.) abandoned.
6g.Screen length(if know a): 15-40 (ft.)