Wake_Well Abandonment_20221222

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WELL ABANDONMENT RECOIL® For Internal Use ONLY:
1.Well Contractor Information: g altly� WELL ABANDONMENT DETAILS
Steven R. Gerrald DECl�� �# 1L CUG 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well o his lty�. tr^s well construction/depth,only 1 GWi 30 is needed. Indicate TOTAL NUMBER of
aka ff� wells abandoned:r I
4309-B0-
NC Well Contractor Certification Number 7b.Approximate volume of water,remaining in well(s): 1 5 (gal.)
Leaf Environmental & Engineering, P.C. .ten i FOR WATER SUPPLY WELLS ONLY:
Company {�"'s^ ( C
P y Name �T...¢ �-� t`--� "�"
7c.Type of disinfectant used:
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,StakJ_ an ) o n
7d.Amount of disinfectant used:'
3.Well use(check well use):
Water Supply Well: i tr 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a 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-Well— -- — ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips -40 Ibs
❑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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity pour Bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 12/14/22
5a.Well location:
Will Newton
Facility/Owner Name Facility ID#(ifapplicable) 8.Certi ation:
104 Bayleaf Drive, Raleigh, NC 27615 12/14/22
Physical Address,City,and Zip A66e of Ce ed Well Contract or Well Owner Date
Wake
By signing this form, I hereby certify that the wells) 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 ivell owner.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I';
(ifwell field,one lattlong is sufficient) 9.Site diagram or additional well details:
35.917336 N 78.644895 W You may use the back of this page to provide additional well site details or well
abandonment details. Youmay also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS,
Attach well construction record(s)ifavailabte.For multiple hyection or non-water supply wells
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 ID#: MW-7 abandonment to the following:
rvrsion of iiter<Resources Information Processing^Un ;�
25 163 7 Iail,Service Center;Raleigh NG 27699-1617�f
6b.Total well depth: (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter:
6 (in.) above,also submit one copy of tliis.form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface:
16 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ce i ter,Raleigh,NC 27699-1636
15 10c.For Water Sunaly&Iniecti i n,Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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
611 Inner casing/tubing length(if known): NA (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016