Moore_Well Abandonment_20240918

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WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
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Jason W. Pendley •
7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owaerpersonally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4360-A wells abandoned:
I
NC Well Contractor Certification Number 76.Approximate volume of water remaining in well(s): 82'5 (gal.)
American Environmental Drilling, Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
52212
List all applicable well construction permits(Le.UIC.County,State,Variance.etc)ifknown
7d.Amount of disinfectant used:
1
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
DAgricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout s Dry Clay
❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 Drill Cuttings
_ _UIaigation — -- __,_❑Specialty Grout _-- __ O Gravel. - - — — , —
Non-Water Supply Well: 0 Bentonite Slurry 0 Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 30 Bags Bentonite Chips
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑StormwaterDrainage 2 Tons Dry Clay
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer: Well Chlorinated. Filled in well with Bentonite chips.
OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Filled in 5'6"deep pit with dry clay.
September 07,2024 . ,
4.Date well(s)abandoned: i `' ►..,;a..'!y�e'..A`,;
5a.Well location:
Edward Monroe SEP .. 7
Facility/Owner Name Facility ID#(if applicable) 8.Ce . I cation: lr s3:P.-y6:t;r a; rrrc ;,
• 76 Fields Road Pinehurst, NC 28374 Dialer `9',0-24
, e46"ed4.„,
Physical Address,City,and Zip joilure of Certified ell Contactor ell Owner Date
Moore
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with ISA 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.19906 N 79.46478 W You may use the back of this page to provide additional well site details or well
— - abandonment-details—You-may-also attach-additionalpages-if necessary.
- ——
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple injection or non-watersupply wells
ONLY with the same construction/abandanment,you can submit one jorm 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: abandonment to the following.
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 100 (ft)•
1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
6
(in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I'
6d.Water level below ground surface: 45 (lt-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 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
6f.Inner casing/tubing length(if known): (ft-) abandoned.
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources { Revised 2-22-2016