13019_Planters Oil Mill_O_2012

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
11 n A !1!
WF,11, CONTRACTOR CERTIFICA
1. WELL CONTRACTOR:
larnes D. Baker
Well Contractor (IndividuaD Name
oiiqDtex, Inc
Well Contractor Company Name
STREET ADDRESS P O Box 41673
NC 27629
City or Town State Zip Code
( (419 ) _ 91 a-a6n4
Area code - Phone number
2. WELL INFORMATION: '' r
SITE WELL ID # (if applicable) �n ►^r �'
STATE WELL PERMIT # (if applicable) NA
COUNTY WELL PERMIT # (if applicable) NA
DWQ or OTHER PERMIT # (if applicable) NA
WELL USE (Check applicable use): is Monitoring ❑ Residential
❑ Municipat/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery ❑ Injection El Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTYNash QUADRANGLE NAME NA
NEAREST TOWN: 1004 COkeV Rnad
-RnrkV Mount North C a[olina 97801
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley 0 Flat ❑ Ridge ❑ Other
(Check appropriate setting)
2(:� �� �$ May be in degrees,
LATITUDE minutes, seconds, or in a
LONGITUDE � 7 ' � 9 � O
decimal format
Latitude/longitude source: 0 GPS ❑ Topographic map
(Location of well must be shown on a USGS topo map and
attached to this form if not using GPS.)
4a. FACILITY- The name of the business where the well is located. Complete 4a and4b
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable) NA
NAME OF FACILITYCdt)Lof Rocky Mot Int
STREET ADDRESS 1004 C'nkeV Rnad
gorky Motlnt NC 27802
Citv or Town State Zip Code
4b. CONTACT PERSONIWELL OWNER:
STREET ADDRESsRockv u• • ► :1
T
WELL DETAILS:
a. Total Depth: 18 ft. Diameter: 1" in.
b. Water Level (Below Measuring Point):_ ft.
Measuring point is (_0 n) ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): NA ft. 1„ in.
b. Casing Removed: ft. in.
7. DISINFECTION: CIA Monitorinfl well
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Cement 9— lb. Cement — lb.
Water 2.5 gal. Water — gal.
Bentonite
mar
Bentonite lb.
; ",„
Type: El Slurry ❑Pellets
7
f v�
Water gal
�l
Other
rlSr✓✓L
Type material
Amount
_S.
9. EXPLAIN METHOD OF EMPLACEMENT
OF MATERIAL:
Pumped Neat Cement through
1/2" threaded PVC pipe,
bottum-up method.
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsused.
11. DATE WELL ABANDONED 9/12112
I DO EBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WIT 1 A NCAC C, WEL NS RUCTION STANDARDS, AND THAT A COPY OF
THIS CORD BEE VI ED TO THE WELL OWNER.
9/13/12
SIG ATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DAM
(The private well owner must be an individual whoWrsonally abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
James D. Barker
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days.
Attn: Information Management,1617 Mail Service Center— Raleigh, NC 27699-1617, Phone No. [phone] ext 568.
Form GW 30
Rev. 5/06

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #3106
1. WELL CONTRACTOR:
t.gmes n Baker
Well Contractor (Individual) Name
O I�antPx, Inc
Well Contractor Company Name
STREET ADDRESS P O Box 41673
Raleigh NC' 27699
City or Town State Zip Code
( 919 ) - 91 Q-g604
Area code - Phone number
2. WELL INFORMATION: I
SITE WELL ID # (if applicable) —AA V V
STATE WELL PERMIT # (if applicable
COUNTY WELL PERMIT # (if applicable) NA
DWQ or OTHER PERMIT # (if applicable) NA
WELL USE (Check applicable use): IZ Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery ❑ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTYNash QUADRANGLENAME NA
NEAREST TOWN: 1004 Coke VRnad
RorkVMount, North Carolina 27801
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope []Valley fa Flat ❑ Ridge ❑ Other
(Check appropriate setting)
?Jt� �� 2
May be in degrees.
LATITUDE _ /_
minutes, seconds, or in a
LONGITUDE 17��
decimal format
Latitude/longitude source: Ia GPS []Topographic map
(Location of well must be shown on a USGS topo map and
attached to this form if not using GPS.)
4a. FACILITY- The name of the business where the well is located. Complete 4a and4b
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable) NA
NAME OF FACILITY(ItV of Ro ckV Mot int
STREET ADDRESS 1004 ('nkek Rnad
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAME ('itV of Rockv Mo int 331 S Franklin Street
STREET ADDRESSRnr nUot N(: 27802
5. WELL DETAILS:
a. Total Depth: 18' ft. Diameter: 1" in.
b. Water Level (Below Measuring Point):' ft.
Measuring point is (-0 20) ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
Length Diameter
NA ft. 1„ in.
ft. in.
7. DISINFECTION: NA Monitoring well
(Amount of 6517v-75% calcium hypochlorite used)
8. SEALING MATERIAL:
NNtal-CLuIcULt�E! Q1L
Cement 5.5— lb.
Water 2.5 gal.
Ben►onite
Bentonite lb.
Type: ❑ Slurry []Pellets
Water gal
Other
Type material --
Amount =
Cement ~ lb.
Water gal.
Net��
cep
Nk ---->
PVC
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Pumped Neat Cement through
1/2" threaded PVC pipe, bottum-up method.
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsused.
11. DATE WELL ABANDONED 9112/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 1 CAC 2C WELL C STRUCTION STANDARDS, AND THAT A COPY OF
THIS CO D HAS EN P [D TO THE WELL OWNER.
,,' 9/13/12
SIGNAT E OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual whoMrsonally abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
James D. Barker
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW 30
Attn: Information Management, 1617 Mail Service Center — Raleigh, NC 27699-1617, Phone No. [phone] ext 568. Rev. 5/06

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # UM
1. WELL CONTRACTOR:
James rl Barker
Well Contractor (Individual) Name
O''antpx, In
Well Contractor Company Name
STREET ADDRESS PO BoY 41673
�alpinh N(' 97699
City or Town State Zip Code
( 919 ) - 919-9604
Area code - Phone number
2. WELL INFORMATION: M W
-3SITE WELL ID # (if applicable)
STATE WELL PERMIT # (if applicable) NA
COUNTY WELL PERMIT # (if applicable) NA
DWQ or OTHER PERMIT # (if applicable) NA
WELL USE (Check applicable use): 0 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery ❑ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTYNash QUADRANGLE NAME NA
NEAREST TOWN: 1 0n4 Cnkev Road
RorkvLmouot North (arnlinn 77S01
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley 0 Flat ❑ Ridge ❑ Othe
(Check appropriate setting)
35 q?�13g0 May be in degrees,
LATITUDE _ minutes, seconds, or in a
/J decimal format
-7
LONGITUDE l7_ -1
Latitude/longitude source: 0 GPS ❑ Topographic map
(Location of well Hurst be shown on a USGS lopo map and
attached to this form if not using GPS.)
4a. FACILITY- The name of the business where the well is located. Complete 4a and4b
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable) NA
NAME OF FACILITY (Itv of RorkV Mount
STREET ADDRESS 1004 ( nkpV Rnnd
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAMEC'itV of RnrkV Mount 331 S. Franklin Street
STREET ADDRESSRc)rV Mount NCB 97809
5. WELL DETAILS:
a. Total Depth: 18' ft. Diameter: 1 " in.
b. Water Level (Below Measuring Point):'
Measuring point is r-0?n) ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): NA ft. ill — in.
b. Casing Removed: ft. in.
7. DISINFECTION: NA Monitoring well
(Amount of 65%75%o calcium hypochlorite used)
8. SEALING MATERIAL:
N GtteaLGkaent
Cement 5— lb.
Water i 5 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry ❑Pellets
Water gal.
Other
Type material --
Amount -
Cement ~ lb.
Water gal.
NeRJ
lttd Pv� y
Z�SER-
screeoN 'y
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Pumped Neat Cement through
1/2" threaded PVC pipe bottum-up method.
IN
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsused.
11. DATE WELL ABANDONED P/17/1
qDREBY CE TIFY T T T IS WELL WAS ABANDONED IN ACCORDANCE
A NCAC , WEL O TRUCTION STANDARDS, AND THAT A COPY OF
CORD H EEN OV EDTOTHEWELLOWNER.
9/13/12
URE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual whoMrsonally abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
James D. Barker
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW-30
Attn: Information Management,1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] ext 568. Rea. 5i06

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 310E
1. WELL CONTRACTOR:
.tames n Barker
Well Contractor (lndividuaD Name
QIji3J1tP.X, Inr
Well Contractor Company Name
STREET ADDRESS P n Box 41673
$ajpogh NC 9769A
City or Town State Zip Code
( A 19 ) - 9 19-9604
Area code - Phone number , I
2. WELL INFORMATION: M
L.1
SITE WELL ID # (if applicable) 1
STATE WELL PERMIT # (if applicable) NA
COUNTY WELL PERMIT # (if applicable) NA
DWQ or OTHER PERMIT # (if applicable) NA
WELL USE (Check applicable use): fa Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery ❑ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTYNash QUADRANGLE NAME NA
NEAREST TOWN: 1 flnd Gnkt-V Rnad
RnrkV Mnu t North raralina 97801
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley 0 Flat ❑ Ridge ❑ Other
(Check appropriate setting)
35
May be in degrees,
,
LATITUDE _y
minutes, seconds, or in a
�t —I(_
decimal format
LONGITUDE _ _ ✓ v`v
Latitude/longitude source: V GPS ❑ Topographic map
(Location of well must be shown on a USGS topo map and
attached to this form if not using GPS.)
4a. FACILITY- The name of the business where the well is located. Complete 4a and4b
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable) NA
NAME OF FACILITY CjtV of RorkV Mount
STREET ADDRESS 1004 (nkav Road
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAME('OtV of Rocky Mount 331 S Franklin Street
STREETADDRESSRony Mniinit Nr 97809
5. WELL DETAILS:
a. Total Depth: 1 S' ft. Diameter: 1" in.
b. Water Level (Below Measuring Point):— ft.
Measuring point is (-020) ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
Length Diameter
NA ft. '1'_� in.
— ft. in.
7. DISINFECTION: NA Mnnitnrinn well
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
N nteDement
Cement 5.5— lb.
Water 2g.5 gal.
Bentonite
Bentonite lb.
Type: ❑ Slurry ❑Pellets
Water gal
Other
Type material =
Amount =
Cement ^- lb.
Water ^ gal.
;� 1 h4
eLSct-
GCree
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Pumped Neat Cement through
1/2" threaded PVC pipe bottum-up method.
t
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsused.
11. DATE WELL ABANDONED Q/17/1 9
I DOH BY CERTIFY THA THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 5 NCAC 2 WELL NS RUCTION STANDARDS, AND THAT A COPY OF
THIS E RD HA EEN P I ED TO THE WELL OWNER. -, f AIA
9/13/12
SIGNATtIrroF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual whoMrsonally abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
James D. Barker
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form G W 30
Attn: Information Management,1617 Mail Service Center— Raleigh, NC 27699-1617, Phone No. [phone] ext 568. Rev. 5/06

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # UM
1. WELL CONTRACTOR:
_lamps n Rarkpr
Well Contractor (Individual) Name
Quantpx, Inc
Well Contractor Company Name
STREET ADDRESS P O Rox 41673
$Hipjph NC 77679
City or Town State Zip Code
( 919 ) - 719-9604
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) Y V
STATE WELL PERMIT # (if applicable
COUNTY WELL PERMIT # (if applicable) NA
DWQ or OTHER PERMIT # (if applicable) NA
WELL USE (Check applicable use): 0 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery ❑ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTYNash QUADRANGLE NAME NA
NEAREST TOWN: 1004 CnkeV Road
RnrkV Mount North Carolina 27801
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley 0 Flat ❑ Ridge ❑ Other
(Check appropriate setting)
LATITUDE May be in degrees,
p minutes, seconds, or in a
LONGITUDE I • � 1 1 4604 decimal format
Latitude/longitude source: 0 GPS ❑ Topographic map
(Location of well must be shown on a USGS topo map and
attached to this form if not using GPS.)
4a. FACILITY- The name of the business where the well is located. Complete 4a and4b
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID #(if applicable) NA
NAME OF FACILITYC'OtV of RnckV Mnunt
STREET ADDRESS 1004 Cnkey Rnad
Rorke Mmint NC ?7R09
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAMECtV of Rocky Mount 331 S Franklin Street —
STREETADDRESSRnckV Mnunt, NC 97809
5. WELL DETAILS:
a. Total Depth: 18' ft. Diameter: 1" in.
b. Water Level (Below Measuring Point): - ' ft.
Measuring point is (-0 90) ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): NA ft. '�_ in.
b. Casing Removed: ft. in.
7. DISINFECTION: NA Monitnrinn well
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement .5.5— lb. Cement - lb.
Water 9-S gal. Water ~ gal.
Bentonite
Bentonite lb. Gr �
Type: ❑ Slurry ❑Pellets 4
Water gal. ` PV L
Other �sez 4
Type material
t
Amount l a
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Pumped Neat Cement through
1/2" threaded PVC pipe, bottum-up method.
10. WELL DIAGRAM: Draw a detailed sketch of the well on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials used.
11. DATE WELL ABANDONED 9/17/1 9
1 DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WI 15A NCAC 2 WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
T IS ECO HA E PROVIDED TO THE WELL OWNER.
d+ 9/13/12
SIG TURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual whopgrsonally abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
James D. Barker
PRINTED NAME OF PERSON ABANDONING THE WELL
Submit a copy to the owner and the original to the Division of Water Quality within 30 days. Form GW 30
Attn: Information Management, 1617 Mail Service Center- Raleigh, NC 27699-1617, Phone No. [phone] ext 568. Rev. 5/06