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Home My WebLink AboutRandolph_Well Abandonment_20230113 (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 JAMES MORRISON 7a.Number of wells being abandoned: 1 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 constructioWabandonment,you can suborn one form. C - 4421 11 NC well Contractor Certification Number 7b.Approximate volume of water remaining i 5 n well(s): 2 (gal.) GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name k T ~ 7c.Type of disinfectant used: 4 2.Well Construction Permit#: / List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown AIV r 7d.Amount of disinfectant used: l M t 'r 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): r , PP y ❑Neat Cement Grout ❑Bentonite Chips-or Pe)1'ets l f fti•1 ❑Agricultural ❑Municipal/Public ❑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: 21 Bentonite Slurry ❑Other(explain under 7g) ElMonitoring ❑Recovery Injection Well: 711 For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation 6.5 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 TREMIE PIPE WITH BENTONITE SLURRY ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 10/24/22 5a.Well location: 6 I QUALITY FABRICATORS Facility/Owner Name Facility ID#(ifapplicable) 8•Certification: 170 PARKS CROSSROADS CHURCH RD RAMSEUR 27316 11/04/22 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date RANDOLPH By signing this farm, I hereby certify that the well(s)was (were)abandoned in County Parcel Identification No.(PIN) accordance ivith 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the ivell owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (if well field,one lot/long is sufficient) 9.Site diagram or additional well details: 350 44' 36.43" 790 34' 46.31" 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(5)if available. For multiple it jection 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-2 abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total well depth: 40.0 (ft-) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b. For Infection Wells: In addition to sending the form to the address in 10a 20 above,also submit one copy of this form within 30 days of completion of well . 6c.Borehole diameter: (in.) abandonment to the following: Gd.Water level below ground surface 23.0 (ft.) 'Division of Water Quality,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 I0c. For Water Sunaly&Iniectioti 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 where abandoned. 6E Inner casing/tubing length(if known): (ft.) 6g.Screen length(if known): (ft.) I Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013 1 Ij WELL.ABANDONMENT RECORD For Internal Use ONLY: This form can be used for single or multiple wells i . I.Well Contractor Information: WELL ABANDONMENT DETAILS JAMES MORRISON i 7a.Number of wells being abandoned: Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or nott-water .supply wells ONLY with the .saute construction/abandonment,you can submit one form. C - 4421 1 I NC well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 2'S (gal.) GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name 7e.Type of disinfectant used: ', T 2.Well Construction Permit List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: JAIV , vi: t l 3.Well use(check well use): 7e.Sealing materials used check all that apply): Water Supply Well: g ( ,� , ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips'lor-Pellets'"'J ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) D Sand Cement Grout ❑ Dry Clay ❑industrial/Commercial ❑Residential Water Supply(shared) D Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑Specialty Grout ❑ Gravel Non-Water Supply Well: El Bentonite Slurry ❑ Other(explain under 7g) ElMonitoring ❑Recovery Injection Well: 7E For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation 6.5 GALLONS ❑Aquifer Storage and Recovery ❑Salinity Barrier El Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA TREMIE PIPE WITH BENTONITE SLURRY DGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 10/24/22 5a.Well location: QUALITY FABRICATORS Facility/Owner Name Facility ID9(ifapplicable) 8•Certification: 170 PARKS CROSSROADS CHURCH RD RAMSEUR 27316 .° +•a 11/04/22 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date RANDOLPH By signing this form, 1 hereby certify that the ivell(s)was (were) abandoned in County Parcel Identification No.(PIN) accordance with 15A 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: (if well field,one lat/long is sufficient) 9.Site diagram or additional well details: 350 44' 36.55" 790 34' 46.16" 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 h jection or eat-water supply wells ONLY with the saute construction/abandotmtent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 11 6a.Well ID#: MW-3 abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total well depth: 40.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b. For Injection 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: 21.0 (ft.) Division of Water Quality,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 10c.For Water Supply&Injection 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 6E Inner casing/tubing length(if known): (ft.) where abandoned. 6g.Screen length(if known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013 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 JAMES MORRISON 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-crater supply hells ONLY with the sauce construction/abandonment,you can submtl one form. C -4421 NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'S (gal) GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: .... 2.Well Construction Permit 4: List all applicable hell construction permits(i.e.County,State,Variance,etc.)ifknou'n 7d.Amount of disinfectant used: JA 1 r 3.Well use(check well use): V i'.::.. .�., Water Supply Well: 7e.Sealing materials used(check all that apply)': :a t ❑Neat Cement Grout ❑ Benton'itii`Chi``soC Pellets, ❑Agricultural ❑Municipal/Public P ❑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: 21 Bentonite Slurry ❑ Other(explain under 7g) OMonitoring ❑Recovery injection Well: 7E For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation 5.75 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 TREMIE PIPE WITH BENTONITE SLURRY ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 10/24/22 Sa.Well location: QUALITY FABRICATORS Facility/Owner Name Facility ID#(if applicable) 8.Certification: 170 PARKS CROSSROADS CHURCH RD RAMSEUR 27316 11/04/22 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date RANDOLPH By signing this form, I hereby certify that the ivell(s)was (1vere) abandoned in County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwcll field,one lat/long is sufficient) 9.Site diagram or additional well details: 35e 44' 36.31" 790 34 46.11 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)if available. For multiple injection or non-neater supply wells ONLY with file same constnuction/abandomnent,you can submit one form. I Oa. For All Wells: Submit this form within 30 days of completion of well 6a.Well IDi/: MW-4 abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total well depth: 35.0 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in loa 2.0 above,also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter: (in.) abandonment to the following: 6d.Water level below ground surface 12.5 (ft.) Division of Water Quality,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 i' loc.For Water Supply&Injection 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 where abandoned. 611 Inner casing/tubing length(if known): (ft.) 6g.Screen length(if known): f I , Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised March 2013