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Home My WebLink AboutPender_Well Abandonment_20221118 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 ofwetis being abandoned: N/A Well Contractor Name(or well owner personally abandoning well on his/her pfopimQ For multiple injection or non-water supply wells ONLY with the same construction abrnutonment,you can submit one form 4146A NC Well Contractor Certification Number - 7b.Approximate volume of water remaining in well(s): N/A (gal.) CATLIN Engineers and Scientists g Z�22 FOR WATER SUPPLY WELLS ONLY: Company Name ` 7c.Type of disinfectant used: N/A d��J 2.Well Construction Permit#: N/A List all applicable well permits(i.e.County.State,Variance,Injection,etc.)tfbwwn 7d.Amount of disinfectant used: N/A 3.Well use(check well use): Water Supply Well: 7e.Seating materials used(check all that apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ®Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Irrigation ❑Specialty Grout ❑Gravel Non-Water Supply NN ell: ❑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 —10 Ibs ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StorrwaterDrainage Asphalt Patch _ —2 Ibs ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure. ❑Geothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) All well material removed and backfilled with hydrated bentonite pellets to within 6 inches of surface and topped 4.Date well(s)abandoned: 11/10/2022 with asphalt patch to existing qrade. 5a.Well Location: NCDEQ-VERA HOWARD N/A Facility/Owner Name Facility IIki(ifapplicable) 8.Certification: l 22545 US HWY 17 N., HAMPSTEAD,28443 `!!V November 10,2022 Physical Address,City,and Zip Signature of Certified Well Contractor or el/ t Owner Date P E N D E R N/A By signing this form 1 hereby certify that the well(s)was(were)abandoned in County Parcel Identification No.(PRE accordance with 1 SA NCAC 02C.0100 or 2C 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: 34.4501471 -77.6171548 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 ifnecessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)ifavailable. For multiple iryection or non-water supply well ONLY with the.same construction abandonment,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well 6a.Well IDN: TMW-02 abandortment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in I Oa above,also submit one copy of this form within 30 days of completion 6c.Borehole diameter: 2.25(in.) of well abandonment to the following: 6d.'Water level below ground surface: 4.2(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&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 6f.Inner casing/tubing length(if known): 2(ft.) county where abandoned. 6g.Screen length(if known): 10(ft.) S:\GQ"ROJECTS\NCDEQ-SLP PROJECTS(AIL)_CDF,222183_NCDEQ SLP N ERA HOWARD.GP1 Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013 i N MAP, Ile M { 1> T TMW-01 APPROXIMATE® LOC'ATION OF FORMER STORE` FORMER 500-GAL. MW-02 ® � GASOL-INE'USTS FORME NSERWF .. ISLAND A �s 0 LEGEND •o o� OAbandoned Temporary Monitoring Well (Type II) Approximate Location of Former UST System so •e: - axar,GeoE�y r phics, rNE�S r s ITic ser ommu NOTE:Tank locations were obtained from previous reports prepared by other consultants and are approximate. 40 20 0 40 80 Feet PROJECT TITLE VERA HOWARD FIGURE ATLIN PROPERTY SITE MAP 22545 US HWY 17 N HAMPSTEAD, NC Engineers and Scientists INCIDENT NO I JOB N0. DATE SCALE DRAWN BYICHECKED BY 22841 222183 NOV 2022 AS SHOWN KMC/BJA i 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-water supply wells ONLY with the same cortstnretiorvabrwdarunent,you can submit one form N ypn y..: ;f k':, t' +.__ 7b.Approximate volume of water remaining in well(s): N/A (gal.) NC Well Contractor Certification Number e, CATLIN Engineers and Scientists si�� 2�ZZ FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: N/A 2.Well Construction Permit#: N/A �t d'^ List all applicable well permits fi (ounty,State,Variance,injection,etc.rfrkdown 7d.Amount of disinfectant used: N/A 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑MunicipaVPublic ❑Neat Cement Grout 29Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑Industrial/Comrnercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Irrigation ❑Specialty Grout ❑Gravel Non-Water Supply Well: ❑Bentonite Slung ❑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 _ --10 Ibs lbs. ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stommwater 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. Datc wells)abandoned: 11/10/2022 na.N1 ell Location: NCDEQ-VERA HOWARD N/A Facility/Owner Name Facility lDk(if applicable) g•(�ertification: / 22545 US HWY 17 N., HAMPSTEAD,28443 MA November 10,2022 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Date PEN DER N/A By signing this form I hereby certify that the well(s)was(were)abandoned in County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C 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: 34.4502129 N -77.6170441 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 WELDS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)if available. For medtiple ity'ection or non-water supply well ONLY with the same construction abatulotunent,you can submit one form 10a.For All Wells: Submit this form within 30 days of completion of well 6a.Well IDH: TMW-01 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 12 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniectan Wells: In addition to sending the form to the address in 6c.Borehole diameter: 2.25(in.) IOa 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: 4.1 (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 SuuDIv&Iniectan 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): 2(ft.) county where abandoned. 6g.Screen length(if known): 10(ft.) S:\GPMPROJECTSWCDEQ-SLP PROJECTS(ALL)_CDF\222183_NCDEQ SLP VERA HOWARD.GPJ Adapted from NCDENR-DWR Form GW-30 North Carolina Department of Envuonment and Natural Resources-Division of Water Resources Revised August 2013