Cabarrus_Well Abandonment_20240918 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Frank Beecher 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on histherproperty) well construction/depth,only 1 GW-30'is needed. Indicate TOTAL NUMBER of
3225-A wells abandoned:- �
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2.00 (gal.)
AECOM Technical Services of North Carolina,InC. FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: N/A
List all applicable well construction perm its(1.e.UIC,County,State,Variance,etc.)if Imo wn
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Publio ❑Neat Cement Grout N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout i ❑ Dry Clay
❑IndustriaUCommercial Y�`� [ R�signi"i Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑irri ation J S ❑Specialty Grout ❑Gravel
Non-Water Supply Well: SEP 1 OQ ❑�� Bentonite;Slurry ❑ Other(explain under 7g)
RMonitoring ❑ ecovery
Injection Well: 1r6W',),�zii fir; 7 7E For each material selected above,provide amount of materials used:
❑AquiferRecharge [?'r°tif"&v 7proundwaterRemediation Bentonite Chips-86 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquiterTest ❑StormwaterDrainage Water-4.0 gallons
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❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Slowly added bentonite chipI.
s and ensured there was no bridging
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
taking place. Then added water to hydrate bentonite chips.
4.Date well(q)abandoned: 08.15.2024 The well was abandoned in accordance with 15A NCAC
5a.Well location: 02C .0113. 1
Speedway#7987 0-031793
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
475 Concord Pkw NC 28027
Y N r Concord, 09.10.2024
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Cabarrus 56109768600000 By signing this form, I hereby certify that the well(s) was(were) abandoned to
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has beet:provided to the ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(if well field,one latllong is sufficient) 9.Site diagram or additional well details:
35.40951 N 80.61217 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
Allach well construction record(v)ifavailable. Porntmlliple injection ortton-watersvpplywells
ONLY with the same constructionlabandonmetnt,you can submit one form.
10a. For All Wells: Submit this font within 30 days of completion of well
6a.Well iD#• MW-1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 44.0 (fw) 1617 Mail Service Center,Raleigh,NC 27699-1617
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10b.For iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.0 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
31.72 Division of Water Resources,Underground Injection Control Program,
Gd.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
N/A (ft.) 10c.For Water Supply&iniection Wells: In addition to sending the form to the
address(es)above,also submit onelcopy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 29.0 (fL) abandoned. I
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Gg.Screen length(if known): 15. (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource4 i Revised 2-22-2016
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