McDowell_Well Abandonment_20241025

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Gary Justice 7a.For GeoprobwW I or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
2150-A wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 306 gal.)
Justice Well Drilling FOR WATER SUPPLY WELLS ONLY:
Company Name ^.� 73% clorine
t 7c.Type of disinfectant used:
2.Well Construction Permit#fl WA24-0294
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)iflmown 1/4 GAL
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 ❑Neat Cement Grout _ ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout,",• ' = Dry Qlay
B..Y.. .
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout _ ❑ Drill Cuttings
F
rri ation ❑ Specialty Grout � I ib vel
n-Water Supply Well: ❑Bentonite Slurry ❑Ofer.(explain under 7g)
❑Monitoring ❑Recovery _v
Injection Well: 7E For each material selected"aboVe,p"i•ovlde amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 14 tons dry dirt (est)
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Chlorine,used excavator to fill in
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 10/16/24
5a.Well location:
Venture Construction Sheets
Facility/Owner Name Facility lD#(if applicable) 8.Certification:
2716 Sugar Hill Rd Marion N.0 28752 10/16/24
Physical Address,City,and Zip Sig a re of?fdfid We ontractor, ell Owner Date
Mcdowell
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
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
-—35.651-2B------- -=-N 82:03248-- -- — W You-may_useAhe-back-of this page_to-provide-additionaLvYelLsite-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)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same constructioWabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: 2 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 88 M.) 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: 24 (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:
70 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 88 (ft.) 10c.For Water Sunuly&Infection Wells: In addition to sending the form to the
address(es)above,also submit orie copy 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): (ft.) abandoned.
I
6g.Screen length(if known): (ft)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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