Granville_Well Abandonment_ (16)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
KENNY SARGENT i 1
7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construction✓abandonment,you can submit one faro[.
A -4226 1.75
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used:
2.Well Construction Permit#: ^-
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknoivn 7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that aa&ft1 atiaD f�f :.;.r.:•S,';(� UM
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonit'%mgRiQ01ets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: RI Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA OVERDRILLING/GROUTED WITH TREMIE PIPE
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) AND BENTONITE SLURRY TO IANDFILL SUBGRADE ELEVATION
4.Date well(s)abandoned: 03/28/22
5%Well location:
GRANVILLE COUNTY LANDFILL
Facility/Owner Name Facility ID#(if applicable) S.Certification:
6584 LANDFILL ROAD OXFORD '27565 "" 04/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
GRANVILLE 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
360 22' 14.67" 780 37' 03.68" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the saute construclion/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
Ga.Well ID#• MW-12 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
19.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.0_ above,also submit one copy of this form within 30 days of completion of well
6e.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: 8.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6L Inner casing/tubing length(if known): (ft.) where abandoned.
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6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013