Hoke_Well Abandonment_20241025

. • 4'
I; '
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
T. Benford Graham, Jr. 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-3:0 is needed. Indicate TOTAL NUMBER of
NCWC 2373-A wells abandoned: I
1 0 (After
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Graham & Currie Diversified Drillers, LLC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: HT•
C
2.Well Construction Permit#: Hoke County 4-09-2002
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known 3 oz
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public 0 Neat Cement Gt'�lit ;.: . ' 1> ,. -.,. '13e'h onite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) 0 Sand Cement Gi'ou-'' 1`''°'iL-"!= 'i 4n.Dry'Clay
❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout 0 r T 2 ;"... e0247 Drill Cuttings
❑Irrigation 0 Specialty Grout Cl Gravel
-Non-Water Supply Well:. - -- . s❑-Bentonite-Shnikr P'"-,70.mi:'7-'Oar(explain under 7g)'
❑Monitoring ❑Recovery 1~`'oCu';3t1
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 14 - 50Ib bags i,
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage i
I
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Gcothennal(Closed Loop) OTracer Under supervision of Hoke County Environmental Health Department Inspector,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
We confirmed that no equipment was in well.After the well was chlorinated,we
4.Date well(s)abandoned: 1 0-16-2024 poured the bentonite into the well using the prescribed pour rate.Job Complete.
5a.Well location: '
Mary Harcourt
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
295 Arthur Lane, Aberdeen, NC 28315 , Z y. GLT 3-*
Physical Address,City,and Zip Si_•nar. . Certif ¶I IT?fr •ctor or Well 0 0 151 I I I I I I I.' Date
Hoke
By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record lies 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:
35.08481985255552 N -79.37112035283617 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)([available..For multiple injection or non-water supply wells
ONLY with the sane construction/abandonment,you can submit one 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: 124 (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: 4 (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: 26.5 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
i
6e.Outer casing length(if known): (ft.) 1Oc.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): 15 (ft.)
i
1
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
h