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Home My WebLink AboutBertie_Well Abandonment_20240119 (11) WELL ABANDONMENT RECORD For Internal Use ONLY: jl 1.Well Contractor Information: WELL ABANDONMENT DETAILS Justin Radford 7a.For Geoprobe/DPT or Closed,Ll op Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW'-30 is needed. Indicate TOTAL NUMBER of 3270-A wells abandoned: I i NC Well Contractor Certification Number 7b.Approximate volume of wateri reImaining in well(s): 0.43 (gal.) Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: N/A List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown 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 ❑Neat Cement Grout 1 @4 Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) 19 Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑ 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 ❑GroundwaterRemediation 20 IbS Of BentOnite'' ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StotYttwaterDrainage 15 Ibs Concrete ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Pour ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 01/04/2024 V.5 i 5a.Well location: 2024 Perrytown Service Center- 00-0-0000022792 Facility/Owner Name Facility ID#(if applicable) S.Certification: 526 Sand Hill Road, Colerain, NC 01/05/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Bertie 3801-1432-6555 By signing this form, I hereby certify that the weh(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: 36.138194 N 76.803389 `,l, 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 SUBMITTAL INSTRUCTIONS Attach ivell construction records)ifavailable. For multiple ityection or non-watersupply wells ONLY with the sane construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well lD#: MW-16 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 12.23 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 2 (in.) 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: 9.62 (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 (ft.) loc.For Water Supply&Injection 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 county where 6E Inner casing/tubing length(if known): 2 abandoned. 6g.Screen length(if known): 10 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i I Revised 2-22-2016 I I , WELL ABANDONMENT RECORD For Internal Use ONLY: 4 1.Well Contractor Information: WELL ABANDONMENT DETAILS i Justin Radford 7a.For Geoprobe/DPT or Closed-L'oop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of 3270-A wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water re maining in well(s): 1.51 (gal.) Geological Resources, Inc.- FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: !I 2.Well Construction Permit#: N/A I List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown 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 ❑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) a Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g) PlMonitoring ❑Recovery Injection Well: 7E For each material selected above;provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation 20 Ibs of Bentonite ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage 15 Ibs Concrete i ❑Experimental Technology El Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Pour ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 01/04/2024 p p 5a.Well location: 2024 Perrytown Service Center 00-0-0000022792 _ ►n;;,;;,::r;`.;, r Facility/Owner Name Facility ID#(if applicable) 8.Certification: 526 Sand Hill Road, Colerain, NC �V01/05/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Bertie 3801-1432-6555 By signing this form, /hereby certij}%that the wells) 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. 56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: 36.138194 N 76.803389 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Aitaclrwellconsinictionreeord(s)ifavailable. For multiple injection ornon-watersupplywells ONLY with the same constructioWabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well HNi: IVI W-20 abandonment to the following: !' Division of Water Resources,Information Processing Unit, 6b.Total well depth: 19.61 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 2 (in,) above,also submit one copy of this forin within 30 days of completion of well abandonment to the following: !, ! ! I 10.32 Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail Service Cenier'Raleigh,NC 27699-1636 6e.Outer casing length(if known): n/a (ft.) 10c.For Water Supply&Injection 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 county where 6E Inner casing/tubing length(if known): unknown (ft.) abandoned. I I I 6g.Screen length(if known): unknown (ft) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Rerised 2-22-2016 I � f WELL ABANDONMENT RECORD For Internal Use ONLY: i 1.Well Contractor Information: WELL ABANDONMENT DETAILS Justin Radford 7a.For Geoprobe/DPT or Closed-Lloop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-3'0 is needed. Indicate TOTAL NUMBER of 3270-A wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0.67 (gal.) Geological Resources, Inc. FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: ( JI 2.Well Construction Permit#: N/A j List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknotvn y 7d.Amount of disinfectant used: 3.Well use(check well use): I Water Supply Well: 7e.Sealing materials used(check all,that apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout j ❑ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) S Concrete Grout ❑ Drill Cuttings ❑kri ation ❑ 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 ❑GroundwaterRemediation 20 Ibs of Bentonite ❑Aquifer Storage and Recovery ❑Salinity Barrier 15 Ibs Concrete ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Pour ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) 4.Date well(s)abandoned: 01/04/2024 5a.Well location: 4 Per town Service Center 00-0-0000022792 Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: i�i oy' iZ(j 526 Sand Hill Road, Colerain, NC 01/05/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Bertie 3801-1432-6555 By signing this form, I hereby certify that the well(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: (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: 36.138194 N 76.803389 `,l, 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach tvellconstructionrecord(s)ifavailable. For multiple injection ornon-umtersupplytvells ONLY with the same construction/abandonment,you can submit one form. I' pA 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: M V V`n,—23 abandonment to the following: Division of Water Resources,Information Processing Unit,, 6b.Total well depth: 13.31 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 I; 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 2 above,also submit one copy of this form within 30 days of completion of well abandonment to the following: 9.17 Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface. (ft.) 1636 Mail Service Center;Raleigh,NC 27699-1636 n/a loc.For Water Supply&Injection 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 6E Inner casing/tubing length(if known): 2 (ft.) abandoned. 6g.Screen length(if known): 13 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 I, I �i ,