Granville_Well Abandonment_20220527 (3)

WELL:ABANDONMENT RECORD For Internal Use ONLY:
1.We11.C6ntractor'Iriformation: WELL ABANDONMENT DETAILS
Bi I`,Joe Pay he Jr
J' 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/doth,only l GWI30'is' eeded l_ndlcate TOTAL-NUMBER of
wells abandoned:
45,32 B.'' I -
NC Well Contractor Certification Number 7b.Approximate volume of water iremarning in well(s):; 2 4
Excel-SRP Environmental FOR WATER SUPPLY WELL S;ONLY:
Company;Name;a 7c:Typeofdisinfectantuses:'Chlorination-Ca OCI)2 .
2.W,ell Construction Permit#: unknown ,�.. - v PEJV-
List all applicable well construction permits(i.e.UIC,County,State,Variance,eta)if known ��OZ ` _
7d.Amount of disinfectant used:'
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply): :IRfOfBn Ursit
❑Agricultural ❑Municipal/Public a Neat Cement Grout a Bentonite-Chips� � 9
❑Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) N Concrete Grout ❑Diill'Cuttings
❑hri ation' ❑ Specialty Grout ❑Gravel
Non-Water Supply'Well: ❑Bentonite Slurry ❑Other(explain under 79)
SMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb- Bent6nite32. 1b-
❑AquiferStorage'andRecovery ❑Salinity Barrier
❑Aui fer-Test. ❑Stormwater Drains
q . ge Concrete-8-lb
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief descriptiowofithe abandonment procedure:
❑Geothermal.(ClosedfLogp) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Dropped Galciulrl'Hypochorite tablet into__well casing and
filled.casing With Be .tonite'pellets:and,poured-neat cement
4.Date wells abandoned: 04.25.2022
O until approx. 1-fbgl and poured_concrete,inside casing-to near the
5a.Well location: TOC and placed,,the lid an,the manhole°of the well
Fast Fare NC-525.
Facility/Owner Name Facility ID#(if applicable) e 'nation: -
215 WILL.I,AMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Sijnat0Fof Ceitifi We C trnctor or Well Owner Date
GRANVILLE 192313139147
By signing this form,I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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 field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W 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 or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID# MW-4 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —38.84 (ft) 1617 Mail Service Center,Raleigh;NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (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: —23.50' (ft) Division of Water Resources;Underground`Injectio i'Control Program,
1636 Mail Service•Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): 00 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
6E Inner casing/tubinglength(if known): (ft,) abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Bill Joe Payne Jr
Y y 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-M is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'$ (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
2.Well Construction Permit#: unknown
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)if knorm R 3-oz E e�
7d.Amount of disinfectant used: SS � 1 ,4,w
3.Well use(check well use): MAY
V
Water Supply Well: 7e.Sealing materials used(check all that apply): MA I 2-7 .21rn
22
❑Agricultural ❑Municipal/Public a Neat Cement Grout S Bentonite 9AMtPr0CZ4;"UM
❑Geothermal(Heating/Cooling Supply) El Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay (}V0A0(3
❑hidustrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
[]Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 30-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
filled casing with Bentonite,pellets and poured neat cement
4.Date well(s)abandoned: 04.25.2022 until approx. 1-fbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8•C tion:
215 WILLIAMSBORO RD, Oxford NC, NC 27565 0. 05.24.2022
Physical Address,City,and Zip Signa ified Well *tractor Well Owner Date
GRANVILLE 192313139147
By signing this form, I hereby certify that the wells) 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.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W 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 construction/abandonment,you can submit one form.
10a. For All Wells: Submit this farm within 30 days of completion of well
6a.Well ID#: MW-4R abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: -'35.0 (ft) 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: 4 (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: —23.72' (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Supply&Iniection 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
6f.Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known):
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016