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Home My WebLink AboutChatham_Well Abandonment_20231228 WELL ABANIDONMEN .RECORD For Internal Use ONLY: • 1:Wellcontractor Information:n �, WELL ABANDONMENT DETAILS ri ep ' 7a,For Gcoprobc/DPT or Closest-Loop Geothermal Wells having the saute Well CC.ntractor Nan (or wet owner personally abandoning well on his/her property) well construction/depth,only 1 W-30 is needed. indicate TOTAL NUMBER of a r /] wells abandoned: ifil , ces. {� 71).Approximate volume of water remaining in well(s): 0.2 (gal.) NC Well Contractor Certification Number N.W. Poole Well & Pump Co. FOR WATER SUPPLY WELLS ONLY: HTH Company Name 7c.Type of disinfectant used: 2.1Ycll Construction Permit t4: .��`3 �� 1/2 lb. List all applicable Well can.clruclioii permit. (i.e. UI County,Slate.Variance,etc.)if known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7c.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public 0 Neat Cement I,Vtr— . , /__ Bentonite Chips or Pellets ❑Geothermal(I-Ieating/Cooling Supply) x.esidential Water Supply(single) 0 Sand Cement GrolltC�.�.r . ry Clay ❑lndustrial/Commercial • ❑Residential Water Supply(shared) 0 Concrete Grout DEC ❑ Drill Cuttings ❑irrigation ,Specially Grout 8 2�23 ❑ Gravel Non-Water Supply Well: }❑ 13cntonite SWIRTIllatien PrCc,9�,;n Welter(explain under 7g) ❑Monitoring ❑Rccovcry DWOi OG Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge...: .....l'I. ' ❑Groui)diyater Remedialion 6ViAllfrriefrAk / '" ❑Aquifer Storage and Recovery ❑Salinity Barrier v - ❑AquiferTest II ❑StormwaterDrainage ❑Experimental Technology'• ❑Subsidence Control ; 7 Provide ovide a brief description of the abandonment procedure: ❑Geothermal(Close,d Loop)' ❑Tracer ;, Pr i ,,., ❑Geothermal(i-leaiuig/Cooling Return) ❑Othcr'(czplain under 7g) '' f l ,f _ / 1 , 4.Date well(s)abandoned: ' At. _ � '` / ' Sa \fell location: .. ...... ifili4' all/LY 614-AC40 t Facility/Owner,Name,sll ,'rr',l, • ' , 8.Certification: r n� �` facility ID!{(if pplicablc) 4 4C '" Thy Physical Address,City,Ad Ziti. / ,/ . Signature o 'crtificd Well Contractor or Well Owner Date . - I i it ,• By signing this form. 1 Hereby certify that the well(s) was (were) abandoned in County Parcel Identification No.(PIN) accordance with 15.4 NC.4C 02C.0100 ar 2C.0200 Well Construction Standards y l In,., :r'i and that a copy of this record has been provided to the well owner. 5b.Latitude niu(Ilougi,tule in degrees/minutes/seconds or decimal degrees: Orwell field,one lal/long is sufficient) 9.Site diagram or additional well details: `e,t ,(A��,a;�j N 1- `j" �''`�� \\' You may use the back of this page to provide additional well site details or well. —i--r V �-�' �J abandonment details. You may also attach additional pages if necessary. II nit ,, CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)ijavailable. For multiple.injection in iionoralersupply wells ON'L1'with the.canner construction/abandonment,)rout can suhuii(nne forth]' ' • e ;11.:c„ ,, 'in' it,i • 10a. For MI Wells: Submit this form within 30 clays of completion of well (ia.Well ID//: abandonment to the following: , I,,i.,i l,.'-.,I,i ,,,,,. , I,11 I.:. „_.;;i; •-,+III;u,,.l; I id 11. • Division of Water Resources,Information Processing Unit, Gb.Total well dep(h:i, (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 ,!,I ':I:,ail;;.!'.. li l 1 - •ilir, I- •.1 , lob. For Injection Wells: In addition to sending the form to the address in 10a Gc.Borehole diameter: (in.) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: ii,','n 4;I ;I mr.l ' Gd.Water level below ground surface: ! +(ft.) Division of Water Resources,Underground Injection Control Program, , .i.l l II. 1636 Mail Service Center,Raleigh,NC 27699-1636 Ge.Outer casing length"(if known): ia (ft.) .10c.For Water Supply&Injection Wells: in addition to sending the form to the 11,II I. I ,,,, li • , I addresses)above,also submit one copy of this form within 30 days of completion ,i I of well abandonment to the county health department of the county where r ®'''n abandoned. Gl'.liuncr casinj;lhtbing,letilgch(if known): ,. .,..; ..=��(ft.) 1;il,;t•j).3 0•(' ,,),•)v,,'', Gg.Screen length(if,kindw.n): - • _ (ft.) , ,:I II,• . , I , • Porn ow-30 1 II:J„I t,:LuI.ii ' ''North Carolina Department of Environmental Quality-Division of Water Resource) Revised 2-22 2016 WELL ABANDONMENT RECORD Forlelenial Use ONLY: II I 1.Well Contractor Information: 1 WELL ABANDONMENT DETAILS Barry Norwood , '. 7a.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-3 is needed. Indicate TOTAL NUMBER of 41 65A wells abandoned: I is w NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): , i,i (gal.) N.W. Poole Well.& Pump Co. FOR WATER SUPPLY WELLS ONLY: Company NameHTH 7c.Type of disinfectant used: 2.Well Construction Permit ti: Ell ` ,List all applicable well construction permits(i.e.UIC,County,Stat Variance,etc. 1/2 lb. 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public 0 Neat Cement Grout _ Bentonite Chips or Pellets ❑Geothermal(1-leating/Cooling Supply) esidential Water Supply l (single) �: ry,Clay p y ❑ Sand Cement r•c�u r ❑industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout ❑ Drill Cuttings ❑Irrigation OSpccialty Grout D E L 2 8 2023 wGravel Non-Water Supply Well: ❑ Bentonite Slur 'Nathey(explain under 7g) ❑Monitoring ❑RecoveryceVOG „mule,P CC Injection Well: 7f.For each material se clTeted above,provide amount of materials used: ❑Aquifer Recharge 1 !!/'1 !: ❑Groundwater Reniediation Sf36g#14 px-- 11696449!,..;❑Aquifer Storage and Recovery ❑Salinity Barrier -,, p �"` ❑Aquifer Test ❑StorrnwaterDrainage �i jt�yvf��il �� !-. �, � •y /� , s ,,m it I Ho 10,..11 :r �' �� ❑Experimental Technology ❑Subsidence Control - I.,I',•.:: i,, 7g.Provide a brief description of the abandonment procedr"•>: ❑Geothermal(Closed Loop)- _- ❑Tracer....__. . . � ❑Geothermal(I-leating/Coo�li»g Return) ❑Other'(ezlilain under 7g) P ..,3 re' vok hivro i -fLL6. e � ,seam ,v 4.Date well(s)abandoned:" `� P 1 ` i it 1 t .:I l` .. r 1' 1 • , ,I •fid ' s' , 5a,Well location:..-.. . ... ...._. _ . . . Facilityy/OwnerNalite•,'i •1 l•tt 11 if: , . ,.Facility_ID/I(ifapplicabllee)) 8.Certification: Physical Address,City,and... li1 t y�`� m - ° .. �C� Sn tonne of rtificd Wcll Contractor or Well Owner Date ..I, .. -• By signing this form, i hereby certifj'that the well(s) was (were) abandoned in County Parcel identification No.(PIN) accordance with 15;1 iVCi1C 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/secgnds,or decimal degrees: (if well field,one tat/long is sufficient) '9.Site diagram or additional well details: e S 4 I,t15T1, .._.. N %a `5 l_ . Z.- 1 ry, 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 WELL(S)BEING-ABANDONED Attach well construction record(s)favailable. For multiple injection or,nan-walersupply wells SUBMITTAL INSTRUCTIONS ONLY with thecsanne consUvctiontabandotnent,yot)tali`subn'iit atl e form.' I ;r. R.. r.•-1, ; ,i1i i ,'i.„1 : 10a. For All Wells: Submit this form within 30 days of completion of well Ga.Well iD/1: abandonment to the following: 1 ' Irani ,.li;r I , • n i;I ,,' n,,I;tlr y' ' 1 .`,Ilia:1,1ZI c,: , ,. Division of Water Resources,Information Processing Unit, Gb. Total well depth: 1 (ft.);,;;,,.. 1617 Mail Service Center,Raleigh,NC 27699-1617 '.i '.'`• 'f -i "'1 I1• f"` 'I ' .. 10b.For Inicction Wells: In addition to sending the form to the address in 10a tie.Borehole diameter: (in.) . , ^ above, also submit one copy of this'form within 30 days of completion of well i ,I , ' '' .. abandonment to the following: 6d.Water level below ground surface: (ft.) Division of Water Resources,Underground injection Control Program, l 1`" 1636 Mail Service Center,Raleigh,NC 27699-1636 Ge.Outer casing'leiigtlr'(itt knon): ' i----•- (ft.) .10c.For Water Supply&Injection Wells: In addition to sending the form to the 1"`1' " address(es)above,also submit one copy of this form within 30 days of completion 1 e`,-: of well abandonment to the countY health department of the county where 6f.Inner casing/tubing length if known): l,.Jt..1., .:! (ft.) abandoned. I . G Screen length'' , .. ,,' g. ngth(if kuomvn):--- (ft.) . y., • Forn,GW-30,1"alll Inutilt.pI1) r, ir.,. il'.'r• , s sl, i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For internal Use ONLY: • I.Well Contractor Information: WELL ABANDONMENT DETAILS Barry Norwood , ' 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW130 is needed. Indicate TOTAL NUMBER of 4165A wells abandoned: NC Well Contractor Certi(icatiou Number 7b.Approximate volume of water remaining in well(s): ,.• (gal.) N.W. Poole Well '& Pump Co. FOR WATER SUPPLY WELLS ONLY: . . -k Company Name HTH 7c.Type of disinfectant used: 2.Well Construction Permit#:� " /, .)13- t List all applicable well construction permits i.e.UIC,County,State, I riarce,etc.)ifknown 1/2 �lJ. 7d.Amount of disinfectant used: t 3.Well use(check well use):, Water Supply.Wcll: _ 7c.Scaling materials used(check all that apply): ❑Agricultural ❑Municipal/Public 0 Neat Cement Grout y,Bentonite Chips or Pellets ❑Geothermal(I-teating/Cooling Supply) Sesidential Water Supply(single) 0 Sand Cement +t.. 0 Dry Clay ❑lndustrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Gro I%C L.Lam.i . L DDrill Cuttings ❑Irrigation Specialty Grout DE r StGravel Non-Water Supply Well: l� Z 8 ZOZ3 0 Bentonite Slurry 0 Other(explain under 7g) ❑Monitoring ❑Recovery t,, Injection Well: 7f.For each m3�ei i"a7sCSFtdamomtt of materials used: ❑Aquifer Rechaige '_':!.I!,';!„?; 'OGrouydwater Re_mediation Q�' � r F S ❑Aquifer Storage and Recovery ❑Salinity Barrier t` ^ ,p� ❑Aquifer Test l •I 11 ❑Stormwater Drainage v �' ,., , 6 g 40-, ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop)... . ❑Tracer ... . ❑Geothermal(I Icating/Cooliiig Return) OOlhc�''(t xjilain under 7g) t /r ,Pi g �f .,mil ift 4.Date well(s);abaudtilicd:'' ` , sy .®-? ,(� 1 !! a i. 5a.11'cll location: ai P �/.._ �1I , , a Facility/OwnerNaindi;I, .'11,ai1 '.: ,FacilityIDll(ifapplicable) 8.Certification: Physical Address,City,and Zqt iA.?. 724,--1-40t gnat of rlificd Well Contractor or Well Owner Date i 1 6 ' 44's 'vll ,, ; By signing this form. I hereby certify that the well(s) teas (here) abandoned in County 1 Parcel identification No.(PIN) accordance with 15,4 ArCG1C 02C.0/00 or 2C.0200 Well Construction Standards rind that a copy ojdtis record has been provided to the well owner: 5b.Latitude•and,longitude in degrees/minutes/seconds or decimal degrees: (if well field,one tat/long is sufficient) --.o 9.Site diagram or additional well details: 35 14 y 5.3 ' !' N 4C (_•5 ' NV 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. I; CONSTRUCTION DETAILS OF WELL(S)BEING•ABANDONED SUBMITTAL INSTRUCTIONS Attach well construction record(s)if available. For multiple injection or non-watersupple wells OA'l_Y with the came construct ion/abandonment,you cait siibriiit otie forth. a'• .Irl , .: , I ,!•,li li: • 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: abandonment to the following: :'11: I , t , • .n. ;'.: 1.1, I. , 4,r „,. , Division of Water Resources,Information Processing Unit, Gb.Total well depth:. (ft.) .1 r.; 1617 Mail Service Center,Raleigh,NC 27699-1617 '" ' "': 1 v , ll'w' 11,,'i ' 10b. For Infection Wells: In addition to sending the form to the address in 10a Ge.Borehole diameter: 0 (ill,) above, also submit one copy of this form within 30 days of completion of well i ;'I abandonment to the following: Gd.Water level below ground surface: (ft.) Division of Water Resources,Underground Injection Control Program, " ;IA' 1636 Mail Service Center,Raleigh,NC 27699-1636 Ge.Outer casing length(iflmown):_ (,C< - • (ft.) .10c.For Water Supply&Injection Wells: in addition to sending the form to the ' .1 I In °'' I address(cs)above,also submit one copy of this form within 30 days of completion '• 1 ' t '''p of well abandonment to the county health department of the county where 6f.Inner casing/tubing,length(if known): ` ..• R .I.., . (ft.) abandoned. II tl l�"t.to',I",l e � i Gg.Scrccn length(iflutown):- , - • (ft.) Form GW:30 " '/1' •''"•i II ' I ' I '' NorthtCai'olina Department of Environmental QualityDivision of Water Resources i 61,1.,i•.: , 1 I . p' Revised 2-22-2016