WI0400560_Injection Event Record_20210608

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
Jonathan Grubbs
Well Contractor Name (or well owner personally abandoning well on his/her property)
3001
NC Well Contractor Certification Number
Terraquest Environmental Consultants, P.C.
Company Name
2. Well Construction Permit #: W 10400460
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 Retum)
❑Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
IOther (explain under 7g)
4. Date well(s) abandoned: 3/16/21
5a. Well location:
Sar Express
Facility/Owner Name
1412 South Main Street
0-008026
Facility ID# (if applicable)
Physical Address, City, and Zip
Surry
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36 29' 27.82" N 80 35' 44.07"
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. WeIIID#: INJ1 INJ2
6b. Total well depth: 30 (ft.)
6c. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: 15 (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form GW-30
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: 2
7b. Approximate volume of water remaining in well(s): (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 s Bentonite Chips or Pellets
❑ 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:
50 pounds bentonite INJ1
50 pounds bentonite INJ2
7g. Provide a brief description of the abandonment procedure:
Injectant pushed through geoprobe borings.
Borings backfilled with bentonite.
8. Certification:
Signature of Certified Well Contracto
4/1/21
or Well Owner Date
By signing this form, I hereby certify 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 Iniection 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.
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016