Durham_Well Abandonment_20221208 (2)

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 histher property) Fwmalap/e ayecnan ar,ma-»mc.nvrsv wrJtr OA'LYwah the x re
caunrenon uhexlawuwm wu can.uAma ore juror
4146A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining hl we6(s): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7e.Type of disinfectant used: N/A
2.Well Construction Permit 8: N/A
1:rl au applreablr.11 porn;&fce.Cmmty,stmr.Van..1q cri.et.)fb » 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 ❑Mumcipal/Public ❑Neat Cement Grout gBemorde Chips or Pellets
OGembermal IHeiting/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑fry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) OConcrete Grout ❑Drill Cuttings
❑Irrigation OSpecialty,Grout []Gravel
Non-Water Supply Well: ❑Bentonite Slurry DOther(explain under 7g)
■Monitoring ❑Recovery
Injection Well: 71.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation Bentonite Pellets —25 lbS lbs.
❑Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stamtwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothenrel(Closed Loop) ❑Tsar 7g.Provide a brief description of the abandonment procedure:
❑Geothemial(Heating/Cooling Return) OOther(explain under 7g) 1 well material removed and backfilled wfth hydrated
a: iientonite pellets to e)dsting grade.
4.Date welds)abandoned: 11/25/2022 oft13 2022
5a.Well Location:
NCDEO-FORMER UL COUNTRY STORE
S.Certification:
FacilitylOwtrer Name Facility ml!(if applicade)
6606 LEESVILLE RD., DURHAM,27703 �4r��Cf/ December 1.2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owrer Date
DURHAM N/A By signing/hisform I herebv certify that the wells)was(were)abandoned in
Canty Parcel Identification No(PIN) accordance with 15A NCAC 02C.0100 or 1C Well Construction Standards and
that a copy of this record has been provided to the well owner
5b.Latitude and longitude in degrees/mh.utesiseconds or decimal degrees:
(if welt field,one lat/long is sufficient) 9.Site diagram or additional well details:
35.9340209 -78.7745463 �Y You may use the back of this page to provide additional well site details or well
N abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLISI BEING ABANDONED SIBMITTAL INSTRUCTIONS
A11mhwe11Conntucttanrecord(s)tfawu1able Fwtwfnpfe iryaTimorrom ersappfv
well ONLYwrih the same cwutnr ltan ahanlwmrem,ynu r mbmtt preform 10a.For All Weds: Submit this form within 30 days of completion of well
6a.Well ITN: TMW-04 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total wed depth: 15 (ft.) 1617 Mad Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the foam to the address in
6c.Borehole diameter: 4.25(ln.) IOa above,also submit one copy ofthis forts,within 30 days of completion
of well abandonment to the following:
6d.Water level below ground surface: NM(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.fluter casing length(jf knows,): N/A 10c.For Water Sunnh&trajection"ells: 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(irknowm): 0(ft.) count'where abandoned.
6g.Screen length(dknown): 15(ft.)
S\GD"ROIEMf NCDEQ-SLPPROJEM(A )_CD 1140_NCDEQSIPFORMERW.COI/MRYSfORE.GPJ
Adapted from NCli N -DWR Fom GW-30 North Cuolw DeRumwnt ofEawo .tv.d Netmd Reworces-Diviam ofWuw Rew . Revied Aram 2013

TMW-03
N
TMW-01
TMW-U4
APPROXIMATE LOCATION
OF FORMER 1,000-GAL. UST
MW-4R
® DW-1A APPROXIMATE LOCATION
OF FORMER 550-GAL. UST
MW-1C
® MW-6A
TMW-02
i
r>r
41
LEGEND MW-3R
MW;5R
® Abandoned Temporary
Monitoring Well (Type 1) 1
® Monitoring Well
(Type II)
• Abandoned Monitoring
Well (Type 11) ,
• Abandoned Monitoring
Well (Type III) MW-7
s
Approximate Location
of Former USTs
Parcel Boundary i■
E i, xar Ea hstar �eo rap as, and the GlS User Cornr ty
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
Feet
MoEa FORMER LIL TI%E FIGURE
COLINTRYSTORE CATLIN 606 L ESVIILLE RD SITE MAP
DURHAM, NC 1
Engineers and Scientists
NO. tale WG p WNB XKMD BY
9990 221140 DEC 2022 AS SHOWN KMC/SJO

WELL A$ANMNMENT RECORD For lntemal Ux ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T.CHALMERS,JR. 7a.Numberofwells being abandoned: N/A
Well Contractor Name(or well owner personally abandoning well on his/her property) Fwmuhrplem c/e non o.non-amer.npt4y urlls ONLY with the rarrre
earvrrucnonto m,you can svdmir one form
4146A
NC Well Contractor Certification Number 7b.Approximate valiant of water remaining inwelks): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit 8: N/A
Lstal/appllcade writ Mono,01 Cowry.SO".ran—rc IIY"an,IX)Il non, 7d.Amount of disinfectant used: N/A
3.Well use(check wed use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑P.gicultual ❑Municipal/Public ❑Neat Cement Grout NBentonite Chips or Pellets
❑Geothemul(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
❑tndustial/Cotmercial ❑Residential Water Supply(sharcd) ❑Concrete Grout ODrill Cuttings
❑Irrigation ❑Specialty Grout DGravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Oder(cplain under 7g)
■Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge OGroundwater Remediation Bentonite Pellets -25 lbs lbs.
OAquifcr Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stommater Drainage
❑Experimental Technology ❑Subsideace Control
OGeotlermal(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
DGeothemml(Heating/CcolingReturn) ❑Other(e immder7 - ". / ,qll well material removed and backfilled with hydrated
bentonite pellets to eAsting grade.
4.Date welgs)abandoned: 11/25/2022 DEC 0 8 2022
5a.Well Location: InCOf>ru:isa ?rc;a:.>r:r.g Ur.:.
NCDEQ-FORMER LIL COUNTRY STORE 0-033'F a'*-,3'—G
Facility/Osmer Name Facility IDM(if applicable) S.Certification:
6606 LEESVILLE RD., DURHAM,27703 171�� December 1 2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Ower Date
DURHAM N/A By signing this form I hereby certify that the wells)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with l SA NCAC 02C.0100 or 2C Well Contraction Standards and
that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degreeslmmutes/seconds or decimal degrees:
(if well field,one Iavlong is sufficient) 9.Site diagram or additional well details:
35.9340853 N -78.7746515 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 convochon re d(s)fanoilable For mtdnple oyeRton or rwn-wriernor
well ONLY.&the.smne co 1,wrlon ahmalarweru.wit con"'hoot one form IOa.For All Wells: Submit this form within 30 days of completion of well
6a.WeR IDN: TMW-03 abandonment to the following:
Division of Water Resources,Information Processing Ling,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in
6c.Borehole diameter: 4.25(in.) IOR 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: NM(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 IOc.For Water SuoDly&IniectRip 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(d laown): 0(ft.) county where abandoned.
6g.Screen length(if known): 15(ft.)
S\FROIECNVCDEQ-SIP PROTE7TS(AIL)_CDF1221140NCDEQSIP FORMER Id.000NTRY SfORE.GPJ
Adapted firm NCDEt4R-DWR Form OWJO North Carolw Depvmient ofEnmainent and Natal Rewwces-Diviaim of Water Resource, Revised Augior 2013