Northampton_Well Abandonment_20241101

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Justin Radford 7a.For Geoprobe/DPT 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
3270—A wells abandoned: I
NC Well Contractor Certification Number 7b.Approximate volume of watel remaining in well(s).2'40 (gal.)
Geological.Resources, Inc. FOR WATER SUPPLY WELLS ONLY:
4 Company Name '
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if known
7d.Amount of disinfectant used:;
r
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(checks all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i N Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water,Supply(shared) s Concrete Grout ❑Drill Cuttings
❑ltri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slu
rry i El Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite j 40
❑Aquifer Storage and Recovery ❑Salinity Barrier I
❑Aquifer Test ❑StormwaterDrainage Grout 15
❑Experimental Technology ❑Subsidence Control 7g.provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer 1,
Pour as placement r`
[]Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 08/20/2024 ,4U V J i 2024
5a.Well location: lr,C;,; ,;,e;�, �•_
Rich Square Tire Center 00-0-000030781 r ,•c�.-" 1�''
".uti.0 {-1 i
Facility/Owner Name Facility ID#(if applicable) 8.Certi anon:
413 East Jackson Street, Rich Square, NC 08/20/2024
Physical Address,City,and Zip Signatu f Certified'Fv ell Con for or Well Owner Date
Northampton 5902-82-7402 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 has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well ficid,one lat/long is sufficient) 9.Site diagram or additional well details:
36.2719,95 N 77.27441 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)ifavailable.For multiple injection ornon-watersupply wells
ONLY with the same
A`copn'struction/abandonment,you can submit one form. 10a. For All Wells: .Submit thiss form within 30 days of completion of well
6a.Well ID#• I V'V V—1 abandonment to the following:
Division of Water Resoiire'es,Information Processing Unit,
6b.Total well depth: 29.00 00 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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: 14.03 (ft.) Division of Water Resources,)Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 0 (ft.) 10c.For Water Suimly&Iniecti n IWells: 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): 9 (ft.) abandoned.
6g.Screen length(if known): 20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resource Revised 2-22-2016