Wilkes_Well Abandonment_20240731

YVELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Edward W. Taylor, 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 G W-30 is needed. Indicate TOTAL NUMBER of
2440—^ wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.3 (gal.)
Geonetics Corporation FOR WATER SUPPLY WELLS ONLY:
Company Name
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7c.Type of disinfectant used:
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2.Well Construction Permit w: 1 A
List all applicable well construction permits(t.e.UIC County,State,Variance,etc.)if known
7d Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Mumcipal/Public ❑Neat Cement Grout S Bentonite Chips or Pellets
❑Geothermal(Heatmg/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring U J�a7 overy
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge 3 1 2026-undwaterRemediation Approx. 100 Ibs bentonite
❑Aquifer Storage and Recovery 9&34mty Barrier
❑Aquifer Test jr."3'. £ ^" a rr OStormwaterDrainage chips and pellets
❑Experimental Technology CYf� " ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
Removed manhole cover
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
,1 Measured total well depth and water level
4.Date well(s)abandoned: 07/1 1/2O2'Y Filled well pipe and manhole w/ bentonite pellets
5a.Well location: Hydrated pellets w/water, replaced manhole cover
Harold T. & Linda A. Call 00-0-0000006960
Facility/Owner Name Facility ID#(ifapplicable) 9.Certification:
1728 Statesville Road, N. Wilkesboro, NC 28659 E dwa*-d W. Taylor,Jr 07/12/2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Wilkes 3878-61-2015
By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this retard has been provided to the well owner.
(if well field,one tat/long is sufficient) 9.Site diagram or additional well details:
36.152800 N 81 .11260 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 construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well a w: M W 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 57.5 (R) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2" PVC Pipe (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: 49.0 (ft) Division of Water Resources,Underground Injection Control Program,
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1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): 1 A (ft.) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
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of well abandonment to the county health department of the county where
6f.Inner casing/tubing length(if known): NA (ft.) abandoned.
ft Screen length(if known): NA (ft.)
Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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