Stanly_Well Abandonment_20240903

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Lane S. Hartsell 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
4656—C construction:abandonment,you can submit one farm.
7b.Approximate volume of water remaining in well(s): 0 (gal.
NC Well Contractor Certification Number )
Derry's Well Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c-Type of disinfectant used: Granular
2.Well Construction Permit#: 412579-3
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)J lnrown 1/2 lb.
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ViResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 175 IbS - Bentonite Chips
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage —
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Well was gravity filled with bentonite chips from
❑Geothermal(Heating/Cooling Return) ❑Other lain under 7g)
top to bottom and irrigated with water.
4.Date well(s)abandoned: 5/15/24
Sm.Well location:
Charles D. Burris
Facility/Owner Name Facility ID#(if applicable)
8.Certification:
24322 Old Aquadale Rd, Albemarle 28001 Z-a4. , '!� 5/15/24
Physical Address,City,and Zip Signature ofCcrtified Well Contractor or Well Owner Date
Stanly 16730 By signing this form, 1 hereby certify that the wells)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLM BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well comiruction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same constructiomabandonmem,you can submii one form 10a. For All Wells: Submit this form within 30 days of completion of well
62.Wen ID#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
66.Total wen depth:
28 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
4 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter- (in.) abandonment to the following:
N/A Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: O 1636 Mail Service Center,Raleigh,NC 27699-1636
10c. For Water Supply&Injection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft) 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
6L Inner casing/tubing length(if known): (fL) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

# 9 —Well Diagram 4" Well Diameter
�1 No Casing
Removed
•-- 0' to 28' Filled with
Casing Depth Bentonite Chips
Unknown
28' --Total Well Depth