Wake_Well Abandonment_ (16)

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. CHALMERS,JR. 7a.Number of wells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-watersupply wells ONLYwith the same
constnictionlabandonment,you can submit one form.
4146A
7b.Approximate volume of water remaining in well(s): NIA (gal.)
NC Well Contractor Certification Number
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
y
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit#: NIA NOV I t!- 2022
List all applicable ivell permits(i.e.County,State,Variance,Injection,etc.)ifknown 7d.Amount of disinfectant used: N/A
3.Well use(check well use): CsA/QM0G �.
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout NBentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout El Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irrigation El Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets 25 lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well material removed and backfilled with hydrated
bentonite pellets to existing grade.
4.Date well(s)abandoned: 11/5/2022
5a.Well Location:
NCDEQ-Annie Bowling Property N/A
Facility/Owner Name Facility ID4(if applicable) 8.Certification:
13109 N. ROXBORO ST., ROUGEMONT, NC 27572 November 8.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or ell Owner Date
WAKE N/A By signing this fonn I hereby certify that the mvell(s)mvas(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15.4 NCAC;02C.0100 or 2C i3rell Construction Standards and
that a copy of this record has been provided to the mvell 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:
36.22037936 -78.92734223 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-m-ater supply
well ONLY with the same construction abandonment,your can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: TMW-04 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 4.25(in.) 1Oa 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: 17.41 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): N/A 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
6f.Inner casing/tubing length(if known): 5(ft.) count'where abandoned.
6g.Screen length(if known): 15(ft.)
S:\GINIVROJECTSINCDEQ-SLP PROJECTS(ALL)_CDF\22I053 NCDEQ SLP ANNIE BOWLING PROPERTY.GPJ
Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013