Alamance_Well Abandonment_20241025

WELL ABANDONMENT RECORD Forlatemal Use ONLY.
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1.Well Contractor lnformatiou� WELL ABANDONMENT DETAILS I
David Hardy 7a.For Geoprobe/DPT or Closed-LoopPeothermal Wellshaving the same
Well Contractor Natea(or well owner personally abandoning well on Iddher property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2906-A wells abandoned:
NC Well Contractor Certification Number. 7b.Approximate volume of water remaining in well(s):_-1-tLl�(gai.)
Aqua Drill, Inc. FOR WATER SUPPLY WELLS m ONLY:
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CompanyWao 7c.Type of disinfectant used: /y! // '7O Ole
2.Well Construction Perrmt#:
List all applicable we11 construction pe;m ins It e.WC,County,State,Variance etc)/f nown 7d.Amount of disinfectant aged: ��O
3.Well use(check well use):
Water Supply Well: 7e.Sealing materiels used(checkall that apply):
❑Agricultural ❑blunicipal/Public AfNeat Cem ut�. -r r` ,❑_,Bearomte Chips crPellet
❑Geothemnal(Heatin Cool' 3 ❑Residential Water Supply ;
� � P1Y) PP Y(single) ❑Saud Cement d[6uh, .•-°��.�� +;1 ��';�C�pry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Gt'out O r j 2 i.� L 024 ❑Drill Cuttings
❑Lii lion ❑Specialty Grout ❑Gravel
Noe-Water BnPPly Well: ❑Betuonitq (ts�y;; ;F,� �r�•r ; .},•Cl Qther(explam mtder7g)
❑Monitaring ❑Recovery `" '
C�Ctr';r C'J
Injection Well: 7L For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑AquifeaTest UStormwaterDminage
❑Eutperimental Technology ❑Subsidence Control t747eothermal(Closed Loop) ❑Tracer 7g Provide a brie[description of the ibiundonment procedure:
ern OU ��
❑Geothermal(Heating/Cooling Return ❑01hcr(explain under 7g) / 1✓ /�.t D
4.Date well(s)abandoned:
Sa.Well location: ` l G/AM
Facllity/Owner Name Faatit IM(ifappllcable) L - catta '
P do Ss,CAy,and Zip 1a 1Ltts'I �;, Si Ceutified W ar7ru 0. Date
°7 By.signing this form;I hereby certify that the wells)was(were)abandoned in
County Parcel Idemisastton No.(PIN) accordance with 1 SA NCAC 02C.0100 or 2C.0200 MU Comtrucdon Standards
and that a copy of this recordhav been provided to the well owner.
5b.Latitude and longitude in ads or decimal degrees:
Crfwall sold,ono tat/lo is eumcicat) 9.Site diagram or additional well detar7s:
SUM N y 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 naessary. 9.
CONSTRUCTION DETAILS OF WELLM BEiNG ABANDONED SUBMITTAL INSTRUCTIONS
Amzchv.-Jiconstracdmra rd(s)ifamifable Forantitipleinjeadmornan-watersupplywells
ONLYwith the sane consfracdarr/abandanment,you cmr submit onefa m. 10a.For Al Wells: Submit this form within 30 days of completion of well
6a Well ID#: abandonment to the following:
Division of Water Resources,Information Processing Un%
6b.Total wen depth: 7-3 (tt:) 1617 Mail Service.Certer,Raleigh,NC 27699-1617
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Ift For Injection Wells: m adddion to sending the form to the address in 10a
6c.Borehole diameter: �(in.) above,also'submit ono copy of i form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:_ Ili/ (tt) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Oster casing length(if 3mown): (fL) 10c.For Water Suouly&inlection Wells: In addition to sending the•form to the
addresses)abotre,also submit one copy of this form within 30 days of completion ;
of wall abandonment to tho county,health departmenit of the county where
6E Inner casingitubing length rf known): tft) abandoned.
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6g.Screen length Qf known):
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Penn OW-30 North Carolina Department of Environmental Quality-Division of Water Resources, i Revised2-22-2016
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WELL ABANDONMENT RECORD ForinternalUseCWLY: i
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1.Well Contractor Information: WELL ABANDONMENT DETAILS I
David Hardy 7a.For Geoprobe/DPT or Closed-Loop Geothermal Welishavingthe same
Well Contractor Name(or well owner personally abandoning well on hisJher property) well construction/depth;only 1 GW-30 is needed.ludwate TOTAL NUMBER of
29�6'Q wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water rema:ning in svell(s)c �^1
Aqua Drill, Inc. FOR WATER SUPPLY WELLS ONLY: /
CompanyNamo
• 7e.Type of disinfectant used:
2.Well Construction Permit#:
&V all applicable well coasrructlo+r permits(Le:MC.Coaaty,State V-ionw,eta)y`hWFm
7d.Amount of disinfectant asetb
t
3.Well use(check well use):
Water Supply Well.. 7e.Sealing materials used(ehecicall dtiat apply):
GAgricultural 17MwticipaVPablie %ltteat Cement Graut i ❑Bentomte Chips or Pellets'
DOeothermal(Heating/Coolrpg Supply) OResidential Water Supply(single) ❑Sand Cement Grout i O Dry Clay
171ndustrial(Commercial OResideatial Water Supply(shared) ❑Concrete Grout i 11 Drill Cuttings
E31iri lion ❑Specialty Grout ❑Gravel
Non-Water Supply Well: t]Bentonite Slurry O 0dier(explain"uWq,70; -- :
OMonitoring ClRecmrety
Injection Well: 7f.For each material selected above,provide amount ofmatrs
4014 '
DAquiferitecharge oGmundwaterlternediation �* I
17Aquifer Storage and Recovery USaliuity Barrier
OAquiferTest OStormwatc'Ihatoagc
DExpetimemalTechnology 171lubsidenceContrul
I7Geoih�mal(Closed Loop) O 7g.Provide a brief deseriptten of the abaadanroe>�
❑Geothermal(HeadrWCoahngRetum) E301her( lainunder7g)
4.Date weil(s)abandoned 1 Z 21 7
5a.Wed!oration: IrA -
Fecitit lOwnerName Faci!' WO(ifapplicable)
64F 4
cal Address,Clt,and Zip ln�Lf�✓► - �"[ si o Camw won Date
BY
si it this nn,!It—by gn rg fo ereby certify that the weU(s)was(1vere)abandoned in
Comely Pamael woutification No.(PIN) amrdaoce with 1SA NCAC 02C.0100 or 2C.0200 Well Construction Standards
and rhara copy of this rewrd has hear provided to the tveQowner.
Sb,Latitude and longitude in or deehnal degrees:
(!Ewell Scld.ono ladlong is sufficicot) / 9.Site diagram or additional well ems:
L N �:S"'d W You may use the bade of this page to provide additional well site details or well
abandonment details. You may also atlxh additional pages ifnecessaty. Q
CONSTRUCTION DETAILS OF WEL_I.I:','I BEING ABANDONED MWTA ,INSTRUCTIONS i
Attachwellconsrm*i?itreeord(s)tfavmda61e.For=ftB huac&nornon-rvateersupplywaUs
ONLYwIrhffmsamecansartcuda/abmrdarimeag you ConsabniftaneforoL 103.For AB Wens: Submit ihis'form within 30 days of completion of well
(m•Wen M& abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Totalwetl depth: AN 1617 NLD Service Center,FAle%ANC 27699-1617
lob.For Luieetion Wells: In addition to smiling the form to the address in 10a
6c Borehole diameter: (iv,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: P
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6d.Water level below ground surface: Ft) Division of Water Resources,Underground Injection Control Program,
1636 Moil Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): tft) 10c.For Water Suaaly&Lniection Well In addition to sending the form to the
address(es)above,also submit one copy of this farm within 30 days of completion
i of well abandonment to the county health department of the county whcre
6f.Inner casing/tabing length Gf!mown): abandoned.
6g.Screen length(if known): (tt,)
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Form OW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22 20I6
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