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Home My WebLink AboutWQ0001077_Report_20210121WELL ABANDONMENT RECORD For Internal Use ONLY: 1. Well Contractor Information: Timothy D. Leatherman Well Contractor Name (or well owner personally abandoning well on his/her property) 2888-A NC Well Contractor Certification Number Pyramid Environmental & Engineering, P.C. Company Name 2. Well Construction Permit #: List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known 3. Well use (check well use): Water Supply Well: ❑Agricultural ❑Geothermal (Heating/Cooling Supply) ❑ Industrial/Commercial ❑Irrigation ❑Municipal/Public ❑ Residential Water Supply (single) ❑Residential Water Supply (shared) Non -Water Supply Well: • Monitoring ❑Recovery Injection Well: ❑Aquifer Recharge ❑Aquifer Storage and Recovery ❑Aquifer Test ❑ Experimental Technology ❑ Geothermal (Closed Loop) ❑ Geothermal (Heating/Cooling Return) ❑Groundwater Remediation ❑ Salinity Barrier ❑ Stormwater Drainage ❑ Subsidence Control ❑Tracer ❑Other (explain under 7g) 4. Date well(s) abandoned: Dec. 19, 2019 5a. Well location: Innospec Active Chemicals LLC WQ0001077 Facility/Owner Name Facility ID# (if applicable) 500 Hinkle Lane, Salisbury, NC 28144 Physical Address, City, and Zip Rowan County 049010 Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 35.70793 N -80.39989 WELL ABANDONMENT DETAILS 7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: 7b. Approximate volume of water remaining in well(s): NA (gal.) FOR WATER SUPPLY WELLS ONLY: 7c. Type of disinfectant used: 7d. Amount of disinfectant used: 7e. Sealing materials used (check all that apply): • Neat Cement Grout • Bentonite Chips or Pellets ❑ Sand Cement Grout ❑ Concrete Grout ❑ Specialty Grout ❑ Bentonite Slurry ❑ Dry Clay ❑ Drill Cuttings 0 Gravel ❑ Other (explain under 7g) 7f. For each material selected above, provide amount of materials used: Bentonite 62 pounds Portland cement 32 pounds 7g. Provide a brief description of the abandonment procedure: Slow pour bentonite pellets/chips; slow pour and tremie pipe portland cement 8. Certification: 01/03/2020 Signature of C ified Well ontractor or ell Owner Date By signing this form, I hereby cert5 that the well(s) was (were) abandoned in 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. 9. Site diagram or additional well details: 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 Attach well construction record(s) if available. For multiple injection or non -water supply wells ONLY with the same construction/abandonment, you can submit one form. 6a. Well ID#: MW-9 6b. Total well depth: 50 (ft.) 6c. Borehole diameter: 8 (2"dia. well) (in ) 6d. Water level below ground surfacer 38.85 (ft.) 6e. Outer casing length (if known): 30 (ft.) 6f. Inner casing/tubing length (if known): NA (ft.) 6g. Screen length (if known): 20 (ft.) SUBMITTAL INSTRUCTIONS 10a. For All Wells: Submit this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 10b. For Infection Wells: In addition to sending the form to the address in l0a above, also submit one copy of this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 10c. For Water Supply & Infection 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 abandoned. Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For Internal Use ONLY: 1. Well Contractor Information: Timothy D. Leatherman Well Contractor Name (or well owner personally abandoning well on his/her property) 2888-A NC Well Contractor Certification Number Pyramid Environmental & Engineering, P.C. Company Name 2. Well Construction Permit #: List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known 3. Well use (check well use): Water Supply Well: ❑Agricultural ❑ Geothermal (Heating/Cooling Supply) ❑ Industrial/Commercial ❑Irrigation ❑ Municipal/Public ❑Residential Water Supply (single) DResidential Water Supply (shared) Non -Water Supply Well: ( Monitoring ❑Recovery Injection Well: ['Aquifer Recharge ❑ Aquifer Storage and Recovery ❑Aquifer Test ❑Experimental Technology ['Geothermal (Closed Loop) ❑Geothermal (Heating/Cooling Return) 0 Groundwater Remediation ❑Salinity Barrier ❑Stormwater Drainage ❑ Subsidence Control ❑ Tracer ❑Other (explain under 7g) 4. Date well(s) abandoned: Dec. 19, 2019 5a. Well location: Innospec Active Chemicals LLC Facility/Owner Name 500 Hinkle Lane, Salisbury WQ0001077 Facility ID# (if applicable) , NC 28144 Physical Address, City, and Zip Rowan County 049010 Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 35.70676 N -80.39906 w CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED Attach well construction record(s) if available. For multiple injection or non -water supply wells ONLY with the same construction/abandonment, you can submit one form. 6a. Well ID#: MW-10 6b. Total well depth: 50 (ft.) 6c. Borehole diameter: 8 (2" dia. well) (in.) 6d. Water level below ground surfacer 47.69 6e. Outer casing length (if known): 30 6f. Inner casing/tubing length (if known): 6g. Screen length (if known): 20 NA (ft.) (ft.) (ft.) (ft.) WELL ABANDONMENT DETAILS 7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: 7b. Approximate volume of water remaining in well(s): NA (gal.) FOR WATER SUPPLY WELLS ONLY: 7c. Type of disinfectant used: 7d. Amount of disinfectant used: 7e. Sealing materials used (check all that apply): I Neat Cement Grout In Bentonite Chips or Pellets ❑ Sand Cement Grout ❑ Concrete Grout ❑ Specialty Grout ❑ Bentonite Slurry O Dry Clay ❑ Drill Cuttings O Gravel ❑ Other (explain under 7g) 7f. For each material selected above, provide amount of materials used: Bentonite 63 pounds Portland cement 31 pounds 7g. Provide a brief description of the abandonment procedure: Slow pour bentonite pellets/chips; slow pour and tremie pipe portland cement 8. Certification: \vvv\N 01/03/2020 Signature of Cert. ed Well Contractor or Well Owner Date By signing this form, I hereby cert that the well(s) was (were) abandoned in 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. 9. Site diagram or additional well details: 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. SUBMITTAL INSTRUCTIONS 10a. For All Wells: Submit this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 10b. For Infection Wells: In addition to sending the form to the address in l0a above, also submit one copy of this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 10c. 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 abandoned. Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For Internal Use ONLY: 1. Well Contractor Information: Timothy D. Leatherman Well Contractor Name (or well owner personally abandoning well on his/her property) 2888-A NC Well Contractor Certification Number Pyramid Environmental & Engineering, P.C. Company Name 2. Well Construction Permit #: List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) ifknown 3. Well use (check well use): Water Supply Well: ❑ Agricultural ❑Geothermal (Heating/Cooling Supply) ❑ Industrial/Commercial ❑Irrigation ❑Municipal/Public DResidential Water Supply (single) ❑Residential Water Supply (shared) Non -Water Supply Well: (Monitoring DRecovery Injection Well: ❑Aquifer Recharge DAquifer Storage and Recovery ❑Aquifer Test DExperimental Technology ❑Geothermal (Closed Loop) ❑ Geothermal (Heating/Cooling Return) ❑Groundwater Remediation ❑Salinity Barrier ❑Stormwater Drainage ❑Subsidence Control ❑Tracer ❑Other (explain under 7g) 4. Date well(s) abandoned: Dec. 19, 2019 5a. Well location: Innospec Active Chemicals LLC WQ0001077 Facility/Owner Name Facility ID# (if applicable) 500 Hinkle Lane, Salisbury, NC 28144 Physical Address, City, and Zip Rowan County 049010 Parcel Identification No. (PIN) 5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) 35.70674 N-80.39820 w CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED Attach well construction record(s) if available. For multiple injection or non -water supply wells ONLY with the same construction/abandonment, you can submit one form. 6a. Well m#: MW-11 6b. Total well depth: 69 (ft.) 6c. Borehole diameter: 8 (2" dia. well) On.) 6d. Water level below ground surface; 49.94 (ft.) 6e. Outer casing length (if known): 34 (ft.) 6f. Inner casing/tubing length (if known): NA (ft.) 6g. Screen length (if known): 35 (ft.) WELL ABANDONMENT DETAILS 7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: 7b. Approximate volume of water remaining in well(s): NA (gal.) FOR WATER SUPPLY WELLS ONLY: 7c. Type of disinfectant used: 7d. Amount of disinfectant used: 7e. Sealing materials used (check all that apply): IF Neat Cement Grout IN Bentonite Chips or Pellets 0 Dry Clay ❑ Drill Cuttings ❑ Gravel ❑ Other (explain under 7g) ❑ Sand Cement Grout ❑ Concrete Grout ❑ Specialty Grout ❑ Bentonite Slurry 7f. For each material selected above, provide amount of materials used: Bentonite 75 pounds Portland cement 31 pounds 7g. Provide a brief description of the abandonment procedure: Slow pour bentonite pellets/chips; slow pour and tremie pipe portland cement 8. Certification: 01/03/2020 Signature of Cert ied ell Contractor or Well Owner Date By signing this form, I hereby cert that the well(s) was (were) abandoned in 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. 9. Site diagram or additional well details: 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. SUBMITTAL INSTRUCTIONS 10a. For All Wells: Submit this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 10b. For Injection Wells: In addition to sending the form to the address in l0a above, also submit one copy of this form within 30 days of completion of well abandonment to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 10c. 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 abandoned. Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016