Lee_Well Abandonment_20241014

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Travis Frazier 7a.For Geoprobe/DPT or Closed-LI op Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: I '
4150-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
Charles R. Underwood Inc. FOR WATER SUPPLY WELLS ONLY:
Company Name HTH
7c.Type of disinfectant used: -
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 9 oz
7d.Amount of disinfectant used:
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3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
0 Agricultural ❑Municipal/Public N Neat Cement Grout I, , 0 Bentonite Chips or Pellets
0 Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) ❑ Sand Cement Grout I 1 ❑Dry Clay
❑Industrial/Commercial OResidential Water Supply(shared) ❑ Concrete Grout • 0 Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
—_-Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 71.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement Grout 3 yards
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pumped water out of the well down to the bottorri,
removed upper piece of casing and filled vwitlzi,,
9/24/2024 . .,•t ---._ e. t' —
4.Date well(s)abandoned:
neat cement grout 1` �n-,.. . ...•'1.-
5a.Well location: o r T 1 2024
Lee County i. —
? -r�t:C• t-,. =r t s F
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
'b
1614 Bragg Street, Sanford 27330 �zj"" Lts�
%aura,P-474.•, 10/2/2024
Physical Address,City,and Zip Signature of Certified We ontractor or Well Owner• Date
Lee i.
By signing this form, I hereby certibl that the well(s) 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:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: -
35.280592 79.090995 W You may use the back of this page to provide additional well site details or well
N
— abandonment details. You may also attach additional pages if necessary.
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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 are form.
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 32 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: 20 (in.)
abandonment to the following: i
I I
6d.Water level below ground surface: 19 (ft.) 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&Iniectio i 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
6L Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.) ,
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016