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Home My WebLink AboutRandolph_Well Abandonment_20240301 . , WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Nathaniel Newman 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 GW-30 is needed. Indicate TOTAL NUMBER of 4630C wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.)if;mown 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 Groff:: -* a Bentonite Chips or Pellets ll t1..� ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout 1 L.:V L,. �' e aClay ❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout MAN ?/❑Drill Cuttings ❑Irrigation ❑ Specialty Grout ‘U f❑Gravel Non-Water Supply Well: 0 Bentonite Slut %r,'t,t;;t?r-•; . � 111 'Filer(explain under 7g) • MMCe>y tMonitoring ❑Recovery C4J Injection Well: 7f. For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite 50 lbs ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Concrete _ 16.671bs ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: OGeothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well abandoned in place with hydrated bentonite pellets to within six inches of surface and topped 4.Date well(s)abandoned: 2/20/2024 with concrete to existing grade. 5a.Well location: Liberty Tire and Auto. Inc 00-0-0000018565 Facility/Owner Name Facility ID#(if applicable) 8.Certification: 232 North Greensboro Street, Liberty, NC 27298 !( t� 2/20/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Randolph 8736064939 By signing this form, 1 hereby cert f 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: (if well field,one lat/long is sufficient) 9.Site diagram or additional well details: 35.856305 ,. -79.572282 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 Attach well construction record(s)iifavailable. For multiple injection 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#: M W-1 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 34 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b. For Infection Wells: In addition to sending the form to the address in IOa 6c.Borehole diameter: 8.25 lilt ) 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: 1 7.03 (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): NA (ft) 10c.For Water Suoolv&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 6f.Inner casing/tubing length(if known): 19 (ft.) abandoned. 6g.Screen length(if known): 15 (ft.) Form GW-30 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 Nathaniel Newman 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 I GW-30 is needed. Indicate TOTAL NUMBER of 4630C wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.)if known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): 0 Agricultural ❑MunicipalPublic El Neat Cement Grout In Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 0 Sand Cement Grout r �—``-., � ❑/ Dry Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) 0 Concrete Grout L v L t Vtri uttings ❑Irrigation El Specialty Grout ^� -1 1 �❑ Gravel Non-Water Supply Well: 0 Bentonite Slurry 4 ?N J 1 204 they(explain under 7g) "Monitoring ❑Recoveryrd11�� t Injection Well: 7f.For each material selected,agoySTS0ebh#nt of •materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite ��"''��..••0000 50 lbs ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stormwater Drainage Concrete 16.67 I b s ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer OGeothermal(Heating/Cooling Return) ❑Other(explain under 7g) Well abandoned in place with hydrated bentonite pellets to within six inches of surface and topped 4.Date well(s)abandoned: 2/20/2024 with concrete to existing grade. 5a.Well location: Liberty Tire and Auto. Inc 00-0-0000018565 Facility/Owner Name Facility ID#(if applicable) 8.Certification: � �� 232 North Greensboro Street, Liberty, NC 27298 2/20/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Randolph 8736064939 By signing this form, 1 hereby certifr that the well(s) was (were) abandoned in County Parcel Identification No.(PM) 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: 35.856305 -79.572282 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 Attach well construction record(s)if available. For multiple injection 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#: M W-3 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 33 (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: 8.25 (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: 18.43 (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): NA (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): 18 (ft.) abandoned. 6g.Screen length(if known): 5 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 • WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Nathaniel Newman 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 GW-30 is needed. Indicate TOTAL NUMBER of 4630C wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.) CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: List all applicable well construction permits(i.e.U/C,County,State,Variance,etc.)if known 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑MunicipaUPublic ❑Neat Cement Gr ut• "' +il tonite Chips or Pellets V ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ` L"t �l Clay ❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout MAR i) ] 2024❑ Drill Cuttings ❑irrigation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑ Bentonite Slu "4"66:41't 'r'" ^441 '6ter(explain under 7g) •Monitoring ORecovery DWeci3LG Injection Well: 7f.For each material selected above,provide amount of materials used: [Aquifer Recharge ❑GroundwaterRemediation Bentonite 50 lbs [Aquifer Storage and Recovery ❑Salinity Barrier [Aquifer Test ❑Stormwater Drainage Soil 67.5 I b S ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) OTracer Well abandoned in place with hydrated bentonite ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) pellets to within six inches of surface. Concrete and a.Date well(s)abandoned: 2/20/2024 all metal removed. Soil used to bring opening to 5a.Well location: grade. Liberty Tire and Auto, Inc 00-0-0000018565 Facility/ou ncr Name Facility ID#(if applicable) 8.Certification: 232 North Greensboro Street, Liberty, NC 27298 -72g 7(14'-'' i 2/20/2024 Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date Randolph 8736064939 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: (if well field,one lat/long is sufficient) 9.Site diagram or additional well details: 35.856305 -79.572282 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 Attach well construction record(s)ijavailable. For multiple injection 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#: M W-04 D abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 75 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Injection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 8.25 (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: 17.85 (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 50 (ft) 10c.For Water Suooly&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 6f.Inner casing/tubing length(if known): 70 (ft.) abandoned. 6g.Screen length(if known): 5 (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 Willilll' ` ' N ;. .e, 00 S FORMER DIESEL ® MW-04D UST BASIN 1 ill ED MW-2 ., (CNL) MW-31/ ►.� 6 FORMER WASTE OIL 41----- UST BASIN z m 04 , z N to 0 , 0 I 0 \ \ - . _., .0 FORMER .•' dat LEGEND GASOLINE 4 UST BASIN Monitoring Well 0 ® (Type II) ® Abandoned Monitoring Well (Type II) g OAbandoned Monitoring Well (Type III) _ P O Active Potable f Water Supply Well Approximate Location of Former UST Basin r At Parcel Boundary '' Source Ea%VAA,E-rthstar Geographics.tnd the GIS User worm ,u ity NOTES: 1. Well and former basin locations were obtained from previous 40 20 0 40 80 reports prepared by other consultants and are approximate. ��inimmimmi Feet 2. CNL= Could Not Locate PROJECT TITLE H & M TIRE SERVICE FIGURE 11 / EIIrsT 232 N LGIBERTY NCRO ST SITE MAP Engineers and Scientists 2 INCIDENT NO. JOB NO DATE SCALE DRAWN BY/CHECKED BY 37686 220292 MARCH 2024 AS SHOWN KMC/SJO