5503_LincolnMSWLF_WellAbandonment_DIN26218_20160610

CIVIl/SANITARY /ENVIRONMENTAl ENGINEERS
I
SITE PLANNING/SUBDIVISIONS
Mr. Perry Sugg, PG
Solid Waste Section (SWS)-Division of Waste Management
North Carolina Department of Environmental Quality
21 7 West Jones Street
Raleigh, NC 27603
Re: Well Abandonment and Well Construction Notification
Lincoln County SubtitleD Lined MSWLF, Phase 4
Permit No. 55-03
MESCO Project No. Gl5141.6
Dear Mr. Sugg:
License No. C-0281
SOLID WASTE MANAGEMENT
SUBSURFACE UTILITY ENGINEERING (SUE)
June 10, 2016
Seven observation wells and one monitoring well used for the Phase 3 Design Hydrogeologic Study (DHGS) were
abandoned in accordance with North Carolina Well Standards 15A NCAC 2C.0113(d) entitled "Abandonment of
Wells" on June 3, 2016. These wells were abandoned in preparation for construction of the SubtitleD Lined MSWLF
Phase 4. All eight wells located within the Phase 4 footprint were abandoned to the designed finished subgrade
elevation as stipulated in the Permit to Construct. The abandoned wells locations and details are shown on Figure 1.
The well abandonment records (GW-30) with their corresponding well construction records (GW-1) are attached in
fulfillment of 15A NCAC 02C.Oll4(b).
Four monitoring wells (MW-37, MW-38, MW-39 and MW-40) were converted from observation wells that were built
per North Carolina Well Standards 15A NCAC 2C .0108. Monitoring wells were converted in accordance with
Water Quality Monitoring Plan approved by the SWS. Monitoring well conversion included installation of locking
metal cases, permanent well tags and concrete surface pads. Monitoring well locations, depths and survey data are
shown on Figure 1. Well construction records (GW-1) denoting the revised well ID are attached.
All other wells located outside of the Phase 4 footprint were retained and are planned to be used for future
hydrogeologic investigations as needed. The locations of the retained wells are shown on Figure 1. The well
construction records (GW-1) have previously been submitted in the approved Phase 4 DHGS.
Water quality monitoring per the Water Quality Monitoring Plan will be initiated following Phase 4 construction but
prior to issuance of the Permit to Operate. Results of the water quality baseline monitoring event(s) will be submitted
to the SWS in accordance with permit conditions.
If you have any questions or need additional information, please contact us at [phone] or by email at
[e-mail].
Enclosures
cc: Mr. Mark Bivins
Lincoln County Landfill
PO Box 97, Garner, North Carolina 27529 (91 9) 772-5393
Stev~!~~
Senior Project Manager
PO Box 349, Boone, NC 28607 [phone]
-• • •1 • • -FUTURE PH AS£ 4 WASTE LIMITS
••••••••••••••••••• ES71MATED EX/SliNG WASTE LIMITS
PROf'OS£0 PHASE 4 SUBGRADE CONTOURS
----------~--------EXISTING TOf'OGRAPHIC CONTOURS
--I --I--I-PROP£RTY UN£ (APPROXfMA TE)
-·-•-·-·-·-·-COMPLIANCE BOUNDARY
(250' FROM £DGE: OF WASTE AND 50'
FROM WGE OF PROPE:R TY LINE:)
MW-35 :ji MONITORING WELL EXISTING
OW4·1 -$-~LL ABANDONED (.,!JN£ 3, 2016)
OW4·1 0~ OBSERVATION \!HL EXISTING
GRAPHIC SCALE
i T i
( Dl FEE'!' )
1 mch • 100 ft.
i
,.,.,...-----.... ,\
I \ ' \ \ \
'\",_.,.. .... ---,/')
G15041 FIGURE 1 ~EET NO
FIGURE. J
Well Abandonment Records
WELLABAN ECORD
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#: --..,...--.-,-..,...-----::::------:--:---
List all applicable well construction permits (i.e. VIC, County, State, Variance, etc.) iflmoWII
3. Well use (check well use):
Water Supply Well:
0 Agri cui tural OMunicipal!Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
Olndustrial/Commercial OResidential Water Supply (shared)
Olrrigation
Non-Water Supply Well:
I!!Monltorlng ORecovery
Injection Wclh
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery 0 Salinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeothermal (Heating/Cooling Return) OOther (cxplnin under 7g)
4. Date well(s) abandoned: _6_1_3_1_1_6 ____ _
5a. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County
261897263
Parcel Identification No. (PIN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
_3_5._41_9_8_87 ___ N 81.356199
CONSTRllCTION UETAILS OF WEI,L(S) :BI!;ING ABANDONED
w
Allach well construction record(s) (faWJifaMt~, F'or mJIItlpl~ ln}lliltlon arnon•l\'nlcrsupply wells
ONLY with the same IUJttrtnlctlon/a/larlflrmmmll, ,YOII ~nn ,vrrbmlt onpjflml
6a. WelliD#: OW4-1 --------------------
6b. Total well depth: 3 7 · 7 5 (ft.) ______ ,
6c. Borehole diameter: _6_._5 _____ ,(1n.)
6d. Water level below ground surface: _2_9_._0_0 ____ (ft,)
6e. Outer casing length (if known): _N_O_N_E ______ (Ct.)
6f. Inner casing/tubing length (if known): 22 · 7 5 (ft.)
6g. Screen length (If known): _1_5_._0_0 _______ .(ft.)
I For Internal Usc ONLY:
WELLABANDONMENTDETA~S
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:_, __________________ _
7b. Approximate volume of water remaining in well(s): _O _______ (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:------------------------
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
• Bentonite Slurry
0 Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
0 Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard s gal slurry wt4o% active solids
7g. Provide a brief description of the abandonment procedure:
Verlfled total depth vie sounding. Tremle grouted slurry under pressure from bottom up
while raising tremle pipe. Grouted to designed subgrade 13.31' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after > 2hrs. of abandonment.
8. em-unc.nt.Jon:--_..:::-' ~~---:::·-='~--=~--Signature ofC.rllricd Well Contractor or Well Owner
By signing this form, I hereby certify that the wel/(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
lOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. Fo1· Iniection Wcl!A: In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
lOc. For Water Sunply & Injection Wt!lls: 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
abandoned.
FonnGW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural OMunicipal/Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
0 Industrial/Commercial OResidential Water Supply (shared)
Olrrigation
Non-Water Supply Well:
Ill Monitoring DRecovery
Injection Well:
OAquifer Recharge 0 Groundwater Remediation
OAquifer Storage and Recovery 0 Salinity Barrier
OAquifer Test 0 Stormwater Drainage
OE:xperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeothermal (Heating/Cooling Return) OOther (explain under#21 Remarks)
4. Date Well(s) Completed: 3/20/15 WelliD# QW4-1
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35.419887
----------------------------------------
N 81.356199 w
6. Is (are) the well(s): OPermanent or GZITemporary
7. Is this a repair to an existing well: DYes or lllNo
If this is a repair, jill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: _1 ______________________ _
For multiple injection or non-water supply wells ONLY with the same co11struction, you can
submit one form.
9. Total well depth below land surface: Screen 37 · 75, Sand 38.00 (ft.)
For multiple wells list all depths if different (example-3@200 'and 2@100')
10. Static water level below top of casing: 32.05 (24 hrs. after set) (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.5 (in.)
12. Well construction method: _a_u_g_e_r ____________ _
(i.e. auger, rotary, cable, direct push, etc.)
FORWATERSUPPLYWELLS ONLY:
13a. Yield (gpm) --------Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
29.05 ft. >38.00ft. Unconfined uppermost aquifer in soil
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM I TO I DIAMETER I THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING b!eothermal closed-loon)
.FROM TO DIAMETER THICKNESS .. MATERIAL
+3.00 ft. 6.83 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
22.75ft. 37.75 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18.GROUT
FROM TO MATERIAL EMPLACEMENT M:ETHOD & AMOUNT
0.0 ft. 3.0 ft. Concrete Gravity >1 00 lbs. solids
3.0 ft. 19.0 ft. Bent. Grout Tremie 55 lbs. solids
19.0 ft. 21.5 ft. Bent. Chips Gravity 40 lbs. hydrated
19. SAND/GRAVEL PACK (if annlicable)
FROM TO MATERIAL EMPLACEMENT METHOD
21.5 ft. 38.0 ft. #2 Silica Sand Gravity
ft. ft.
20. DRILLING LOG (attach additional sheets ifnecessarv)
FROM TO DESCRIPTION ( t:olor, hardness, soil!rot:k tvne, arain size, ett:.)
0 ft. 38 ft. SOIL; Brown, soft
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Temporary observation well for hydrogeologic study
for future Ph 4 MSWLF
22. Certification: ~ Date
3/30/15
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L:=..:.::.:::.:::=~::!:::.:=======___:=::::::..=========-1 constructed.
FormGW-1 North Carolina Department ofEnvironment and Natural Resources-Division ofWater Resources Revised August 2013
·v\wh\ (o, MSW LF
5£t9/ (rovse f{J
crouse PJG ;J.81Yi 3
--~--~--~-
•••••••••••••••••••
----810'---
----------250 --------__ , __ , __ ,_
OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
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(ABANDONED)
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GRAPHIC SCALE
( IN FEET )
1 inch = 100 fl
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G15041
DRAlllNG NO. SliEET NO.
8
WELL ABANDONMENT RECORD
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#:--:---::-~:::-=---=---::--:------:-:-:--­
List all applicable well construction permits (i.e. VIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
DAgricultural DMunicipaVPublic
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
DindustriaVCommercia\ DResidentia\ Water Supply (shared)
Dirrisation
Non-Water Supply Well:
!!!Monitoring DRecovery
Injection Well:
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery D Salinity Barrier
DAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (.Heating/Cooling Return) OOther (explnin under 7g)
4. Date well(s) abandoned: _6_1_3_11_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County
261897263
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
35.419087 N 81.356643 ------------
CO STRUCTION DE'fAlLS OF WELL(S) BEING ABANDONED
w
Attach well constroction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same constroclionlabandonment, you can submit one form.
6a. Well ID#: OW4-4 ----------
6b. Total well depth: _3_1_._9_0 ____ .(ft.)
6c. Borehole diameter: _6_._5 _____ .(1n.)
6d. Water level below ground surface: _2_2_. 1_5 ____ (ft)
6e. Outer casing length (If known): _N_O_N_E _____ ,(ft.)
6f. Inner casing/tubing length (If known): _1_6_._9_0 ___ .(ft.)
6g. Screen length (If known): _1_5_._0_0 _______ (ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobeffiPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: 1
7b. Approximate volume of water remaining in well(s): _O ______ (g 11
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:----------------
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
D Neat Cement Grout
D Sand Cement Grout
0 Concrete Grout
D Specialty Grout
Ill Bentonite Slurry
D Bentonite Chips or Pellets
0 Dry Clay
D Drill Cuttings
D Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard s.s gal slurry w/40% active solids
7g. Provide a brief description of the abandonment procedure:
Verlfled total depth via sounding. Tremle grouted slurry under pressure from bottom up
while raising tremle pipe. Grouted to designed subgrade 6.73' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after > 2hrs. of abandonment.
'·""""~ & Dntl{ 1 Signature of Certified Well Contractor or Well Owner
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
lOa. For All Wclls: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. For In!cctlon Well : In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
lOc. For Water Supply & Jn!cctlon 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
abandoned.
FormGW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
WELL CONSTRUCTION RECORD
Tlris form can be used for single or multiple wells
1. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultural DMunicipal/Public
DGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
Dlndustrial/Commercial DResidential Water Supply (shared)
Dlrrigation
Non-Water Supply Well:
0Monitoring DRecovery
Injection Well:
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 3/20/15 Well ID# QW4-4
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35.419087 N 81.356643 --------------------------w
6. Is (are) the well(s): DPermanent or LZITemporary
7. Is this a repair to an existing well: DYes or I?JNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this fonn.
8. Number of wells constructed: _1 __________ _
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: Screen 31.9, Sand 32.0 (ft)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: 21.57 (24 hrs. after set) (ft)
If water level is above casing, use "+"
11. Borehole diameter: 6.5 (in.)
12. Well construction method: _a_u_;;g._e_r _____________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) --------Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
18.57 ft. >32.00ft. Unconfined uppermost aquifer in soil
ft. ft.
1S. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (!!:eothermal closed-loon)
FROM TO DIAMETER THICKNESS MATERIAL
+3.0 ft. 16.9 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
16.9 ft. 31.9 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18~GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >95 lbs. solids
3 ft. 13 ft. Bent. Grout Tremie 35 lbs. solids
13 ft. 15 ft. Bent. Chips Gravity 35 lbs. hydrated
19. SAND/GRAVEL PACKlifannlicable)
FROM TO MATERIAL EMPLACEMENT METHOD
15 ft. 32 ft. #2 Silica Sand Gravity
ft. ft.
20. DRILLING LOG {attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock tvne, !!rain size, etc.)
0 ft. 32 ft. SOIL; Sandy Silt, soft,
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Temporary observation well for future MSWLF Ph 4
hydrogeologic study
22. Certification:
3/30/15
Date
By signing this form, I ereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or l5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this fonn within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L::::.:~:=:::::.::::_~::_======:=~===::...:========:=J constructed.
FonnGW-1 North Carolina Department ofEnvironment and Natural Resources -Division of Water Resources Revised August 2013
L. : V\(0 \ ~\ Cor rA 5 w L. F
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LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
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G15041
DRAlllNG NO. SliEET NO.
8
WELL ABANDONMENT R~CORD
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#:---,--:-::-=--=-----=------,-,-:-:---
List all applicable well construction permits (i.e. UJC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
OAgricultural OMunicipal!Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
0 Industrial/Commercial OResidential Water Supply (shared)
Oirrisation
Non-Water Supply Well:
!!!Monitoring ORecovery
Injection Well:
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeothermal (Heating/Cooling Return) OOther (explain under 7g)
4. Date well(s) abandoned: _6_1_3_11_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County
261897263
Parcel Identification No. (PIN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one ]at/long is sufficient)
35.419470 N 81.356273 ------------------
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
w
Allach 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.
6a. WelliD#: OW4-5 -----------------
6b. Total well depth: _3_1_._2_5 ____ .(ft.)
6c. Borehole diameter: _6_._5 _________ .(1n.)
6d. Water level below ground surface: _2_5_._3_0 ________ (ft.)
6e. Outer casing length (If known): _N __ O_N __ E _________ .(fL}
6f. Inner casing/tubing length (If known): _1_6_._2_5 _____ .(ft.)
6g. Screen length (If tmown): _1_5_._0_0 ____________ ___:(ft.)
I For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well constmction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: 1
0 7b. Approximate volume of water remaining in well(s): ______ .(gnl.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:----------------
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
I!! Bentonite Slurry
0 Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
0 Gravel
0 Other (explain under 7 g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard 5 gal slurry w/40% active solids
7g. Provide a brief description of the abandonment procedure:
Verified total depth via sounding. Tremle grouted slurry under pressure from bottom up
while raising tremle pipe. Grouted to designed subgrade 7.11' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after > 2hrs. of abandonment.
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Constrnction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMlrfAL INSTRUCTIONS
lOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lOb. For ln!ectton Wells: In addition to sending the form to the address in lOa
above, also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
lOc. For Water Supply & In!eciJon WcJis: In addition to sending the fonn to the
address(es) above, also submit one copy ofthis fonn within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
FormGW-30 North Carolina Department of Environmental Quality. Division of Water Resources Revised 2-22-2016
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
L Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural DMunicipal!Public
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Dlndustrial/Commercial DResidential Water Supply (shared)
Dlrrigation
Non-Water Supply Well:
0Monitoring DRecovery
Injection Well:
DAquifer Recharge 0 Groundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquiferTest DStormwater Drainage
DExperimental Technology DSubsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 3/20/15 Well ID# QW4-5
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
5b, Latitude and Longitude m degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35.419470 -----------------------N 81.356273 w
6. Is (are) the well(s): DPermanent or G21Temporary
7. Is this a repair to an existing well: DYes or lliNo
lfthis is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number ofwells constructed: _1-:-----:-:---:::-~..._,--:--:--------
For multiple injection or non-water supply wells ONLY with the same cotrstruction, you can
submit one form.
9. Total well depth below land surface: Screen 31.25, Sand 32.00 (ft)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: 24.55 (24 hrs. after set) (ft)
lfwater level is above casing, use "+"
11. Borehole diameter: 6.5 (in.)
12. WeD construction method: _a_u_g_e_r _____________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ________ Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
21.55 ft. >32.ooft. Unconfined uppermost aquifer in soil
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (2eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
+3.0 ft. 16.9 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
16.9 ft. 31.9 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18;GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >95 lbs. solids
3 ft. 13 ft. Bent. Grout Tremie 305 lbs. solids
13,32 ft. 15,36 ft. Bent. Chips Gravity 35, 60 lbs. hydrated
19. SAND/GRAVEL PACK(ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
15 ft. 32 ft. #2 Silica Sand Gravity
ft; ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, ha•·dness, soil/rock type, ~rain size, etc.)
0 ft. 36 ft; SOIL; Residuum to saprolite, soft,
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft; ft.
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Temporary observation well for hydrogeologic study
for future MSWLF Phase 4
3/30/15
Date
By signing this fom1, I eby certifY that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L::..::..:..:==.:=:=.:~.::.:..:=======__:=:.:.:=~=======:=J constructed.
FormGW-1 North Carolina Department ofEnvironment and Natural Resources -Division ofW ater Resources Revised August 2013
L. : ¥\w \ ~\ (or M S w L. F
5719/ Crovse RJ c f o v s e ;\l c, ;L 8 C:3 3
--~--~--~-
•••••••••••••••••••
----810'---
----------250 --------__ , __ , __ ,_
OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
\
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LEACHATE LAGOON
(ABANDONED)
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GRAPHIC SCALE
( IN FEET )
1 inch = 100 fl
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G15041
DRAlllNG NO. SliEET NO.
8
WELLABANDONMENTRE ORD
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#: --:--::----:c:::-::--=----::----::----:----:-:-::---
List all applicable well construction permits (i.e. VIC, County, State, Variance, etc.) if/mown
3. Well use (check well use):
Water Supply Well:
OAgricultural OMunicipal/Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
0 Industrial/Commercial OResidential Water Supply (shared)
0 Irri~~:ation
Non-Water Supply Well:
!!!Monitoring ORecovery
lnjcctlon Well:
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeothermal (Healing/Cooling Rctu.m) OOther (explnln under 7g)
4. Date well(s) abandoned: _6_1_3_11_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln 261897263
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
35.419634 N 81.358117 -----------
CONSTRUCTION DETAILS OF \'YELL(S) BEING ABANDONED
w
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.
6a. WelliD#: OW4-7 -----------
6b. Total well depth: _3_2_._0_5 ____ .(ft.)
6c. Borehole diameter: _6_._5 _____ .(1n.)
6d. Water level below ground surface: _2_5_._3_0 ____ .(ft.)
6e. Outer casing length (If known): _N_O_N_E _____ (ft.)
6f. Inner casing/tubing length (If known): 17 · 05 (ft.)
6g. Screen length (If known): _1_5_._0_0 ________ (ft.)
[For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells abandone4:...;, _______________ _
7b. Approximate volume of water remaining in well(s) _O ______ (.gaU
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:----------------
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
" Bentonite Slurry
0 Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
0 Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard 5 gal slurry w/40% active solids
7g. Provide a brief description of the abandonment procedure:
Sounded well to verlfy total depth. Tremle grouted slurry under pressure from bottom up
while raising tremle pipe. Grouted to designed subgrade 10.11' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after > 2hrs. of abandonment.
orWell Owner
By signing this form, I hereby certifY that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Constrnction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
lOa. For AJI Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. For Illicctlon Well8: In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
lOc. For Water SuppJy & ·lulectlon 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
abandoned.
ForrnGW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2·22·20 16
WELL CONSTRUCTION RECORD
Tlris form can be used for single or multiple wells
l. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company N arne
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etcJ
3. Well Use (check well use):
Water Supply Well:
DAgricultural DMunicipal!Public
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Dlndustrial/Commercial DResidential Water Supply (shared)
Dlrrigation
Non-Water Supply Well:
0Monitoring DRecovery
Injection Well:
DAquifer Recharge D Groundwater Remediation
DAquifer Storage and Recovery D Salinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control
DGeothermal (Closed Loop) DTracer
D Geothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 3/23/15 WelliD# OW4-7
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.419634
-----------------------------N 81.358117 w
6. Is (are) the well(s): DPermanent or 121Temporary
7. Is this a repair to an existing well: DYes or l?JNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: _1-:----:-:-~-:-----:--:-----------
For multiple injection or non-water supply wells ONLY with the stune COtiStruction, you can
submit one form.
9. Total well depth below land surface: Screen 32.05, Sand 32.50 (ft)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: 23.33 (24 hrs. after set) (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.5 (in.)
12. Well construction method: _a_u_g_e_r _____________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ________ Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
20.33 ft. >32.50ft. Unconfined uppermost aquifer in soil
ft. ft.
15. OUTER CASING (for multi~cased wells) OR LINER (if applicable)
FROM I TO I DIAMETER I THICKNESS I MATERIAL
ft. ft. in.
16.1NNER CASING OR TUBING (~eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
+3.00 ft. 17.05 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
17.05ft. 32.05 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >95 lbs. solids
3 ft. 14 ft. Bent. Grout Tremie 35 lbs. solids
14 ft. 16 ft. Bent. Chips Gravity 30 lbs. hydrated
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
16.0 ft. 32.5 ft. #2 Silica Sand Gravity
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hru·dness, soiVmck type, grain size, etc.)
0.0 ft. 32.5 ft. SOIL; Residuum to saprolite, soft
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Temporary observation well for hydrogeologic study
for future MSWLF Phase 4
3/30/15
Date
By signing this form, I ereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
Y au may use the back of this page to provide additional well site details or well
construction details. Y au may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division ofWater Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniectimi Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L::.:::.=..:.:====-:~.:..:=======_::.::==:...=========J constructed.
FonnGW-1 North Carolina Department ofEnvironment and Natural Resources-Division ofWater Resources Revised August 20 13
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•••••••••••••••••••
----810'---
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OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
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G15041
DRAlllNG NO. SliEET NO.
8
WELL ABANDONMENT RECORD
I. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#: --:--:----::-c:-::::---::---:----:-:-------:-:-:-:---
List all applicable well construction permits (i.e. UJC, Cormty, State, Variance, ere.) ifkrrown
3. Well use (check well use):
Water Supply Well:
OAgricultural OMunicipal/Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
0 Industrial/Commercial OResidential Water Supply (shared)
0 Irrigation
Non-Water Supply Well:
!!!Monitoring ORecovery
Tnjcc.tlon Well:
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeothermal (Heating/Cooling Return) OOther (explain under 7g)
4. Date well(s) abandoned: _6_1_3_11_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County
261897263
Parcel Identification No. (PIN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
35.419634 N 81.358117 -----------------
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED
w
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.
6a. Well ID#: OW4-9S -----------------
6b. Total well depth: _2_9_._2_6 ____ (ft.)
6c. Borehole diameter: _8_._5 ________ _.:(1n.)
6d. Water level below ground surface: _2_1_. 1_1 ____ .(ft.)
6e. Outer casing length (If known): _N __ O_N __ E _________ .(ft.)
6f. Inner casing/tubing length (if known): 14.26 (ft.)
6g. Screen length (If known): _1_5_._0_0 _____________ (ft.)
I For Intemal Use ONLY J
WELLABANDONMENTDET~S
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells ahandoncd;,_1 _______________ _
0 7b. Approximate volume of water remaining in well(s): ______ (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:----------------
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
1!!1 Bentonite Slurry
0 Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
0 Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard 5 gal slurry w/40% active solids
7g. Provide a brief description of the abandonment procedure:
Sounded & verified total depth. Tremle grouted slurry under pressure from bottom up
while raising tremle pipe. Grouted to designed subgrade 7 .59' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after > 2hrs. of abandonment.
Signature of artil1ed Well Contractor or Well Owner
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with l5A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
lOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. ,For ln(ectlon Wells: In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
tOe. For Wate.r Supply & fn(eetton Wells: In addition to sending the form to the
address(es) above, also submit one copy ofthis form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
FormGW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
OW4-9S.
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells I 1. Well Contractor Information:
!For Internal Use ONLY:
John Thompson
Well Contractor N arne
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit#:
List all applicable well penrtits (i.e. County, State, Variance, Injection, etcJ
3. Well Use (check well use):
Water Supply Well:
DAgricultural DMunicipal!Public
DGeothermal (Heating/Cooliog Supply) DResidential Water Supply (single)
Dlndustrial/Commercial dResidential Water Supply (shared)
D Irrigation
Non-Water Supply Well:
0Monitoriog ORecovery
Injection Well:
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery OS alinity Barrier
DAquifer Test D Stormwater Drainage
DExperimental Technology D Subsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 2/27/15 WelliD# OW4-9S
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/mmutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
35.419707 ---------------------N 81.357202 w
6. Is (are) the well(s): DPermanent or [;ZJTemporary
7. Is this a repair to an existing well: DYes or lllNo
If this is a repair, fill out known well con.stroction information and explain the nature of the
repair under #2/ remarks section or on the back of this form.
8. Number of wells constructed: _1-:-~:-::=o;;-'7':'-:-----:-
For multiple injecn·on or non-water supply wells ONLY with the same co11struction, you can
submit one form.
9. Total well depth below land surface: Screen 29.26, Sand 29.50 (ft)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: 24.11 (24 hrs. after set) (ft)
If water level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: _a_u,....:;;g_e_r _______ --'----------
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ----------Method oftest: -----------
14. WATERZONES
FROM TO DESCRIPTION
22.88 ft. >29.5Qfl. Unconfined uppermost aquifer in soil
ft. ft.
·lS.iJUTER CASING (for multi-cased wells) ORLINER_(ifapplicable · ..
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
i6. INNER CASING OR TUBING (~eothenuid clcised~loop) '· .
FROM TO DIAMETER THICKNESS MATERIAL
+3.00 ft. 14.26 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN > :_-:_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
14.26ft. 29.26 ft. 2 in. 0.01" Sch 40 PVC
ft. ft. in. 1/4" space
·1s.GROUT . ... ---.-..
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >190 lbs. solids
3 ft. 11 ft. Bent. Grout Tremie 50 lbs. solids
11 ft. 13 ft. Bent. Chips Gravity 55 lbs. hydrated
· 19;.SAND/GRA Vl!:L P ~_(;;K (if !IIIPlicable)._ ·._ ·•
FROM TO MATERIAL EMPLACEMENT METHOD
13.0 ft. 29.5 ft. #2 Silica Sand Gravity
ft. ft.
20. DIULLING LOG (attach additional sheetS ifnecessatr) '-FROM TO D:ESCRIPTION colo~ hardness, soiVrocktype, ~l'ain size, etc.
0.0 ft. 29.5 ft. SOIL; Residuum to saprolite, soft
ft. ft.
ft. ft.
ft. ft.
ft ft.
ft. ft.
ft. ft. 2'X2' concrete pad with locked steel case
2l.REMARKS :c · .. ' Observation well for hydrogeologic study for future Ph 4 LF
Shallower counterpart to adjacent nested well OW4-90
3/30/15
Date
By signing this fonrt, I he by certifY that the well(s) was (were) constructed In accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construcn'on Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form withio 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction t«;> the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L:=..::===:..:.:~:..=:::::::::::::=:::_:=:=:::.::::::::::::::::=:::::::J constructed.
FormGW-1 North Carolina Department of Environment and Natural Rcsomces-Division ofWater Resources Revised August 2013
L: r\w \ ~\ 0J, tv\. 5 ·w ~ F
5'l9/ (rouse f{J
c -r c v s e ;\l c, ;).zc:3 3
--~--~--~-
•••••••••••••••••••
----810'---
----------250 --------__ , __ , __ ,_
OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
\
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LEACHATE LAGOON
(ABANDONED)
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GRAPHIC SCALE
( IN FEET )
1 inch = 100 fl
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G15041
DRAlllNG NO. SliEET NO.
8
WELL ABANDONMENT RECORD
1. Well Contractor Information:
~:.P.tv Cw·,..v6
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#: --:---::----::-:c~-=---:----:-:----:----:-:-::--­
List all applicable well construction permits (i.e. UJC, County, State, Variance, etc.) if/mown
3. Well use (check well use):
Water Supply Well:
DAgricultural DMunicipal!Public
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
DindustriaVCommercial DResidential Water Supply (shared)
Dirri!!ation
Non-Water Supply Well:
!!!Monitoring DRecovery
fujcction Well:
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (Hen ling!Cooling, Return.) DOther (explain under 7g)
4. Date well(s) abandoned: _6_1_3_1_1_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln 261897263
County Parcel Identification No. (PIN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
35.419635 N 81.358116 -----------
CONSTRUCTION DETAILS OF WELL{S) BEING ABANDONED
w
Attach well construction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment, you can submit onefomr.
6a. Well ID#: OW4-9D
6b. Total well depth: _6_1_._5_8 ____ (ft.)
6c. Borehole diameter: _8_._5 _____ .(1n.)
6d. Water level below ground surface: _2_2_._8_8 ____ (ft.)
6e. Outer casing length (If known): _N_O_N_E _____ .(ft.)
6f. Inner casing/tubing length (If known): _5_1_._5_8 ___ .(ft.)
6g. Screen length (If known): _1_0_._0_0 _______ (ft.)
WELL ABANDONMENT DETAILS
7a. For GeoprobeillPT or Closed-Loop Geothermal Wells having the same
wetl construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wctls abandClned: . ..,;1_;_ ______________ _
0 7b. Approximate volume of water remaining in well(s): ______ (.gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:----------------
7d. Amount of disinfectant used:---------------
7e. Sealing materials used (check all that apply):
D Neat Cement Grout
D Sand Cement Grout
D Concrete Grout
D Specialty Grout
!!! Bentonite Slurry
D Bentonite Chips or Pellets
D DryClay
D Drill Cuttings
D Gravel
D Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard 13 gal slurry w/40% active solids
7g. Provide a brief description of the abandonment procedure:
Sounded & verified total depth. Tremle grouted slutTY under pressure from bottom up
while raising tremie pipe. Grouted to designed subgrade 7 .60' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after > 2hrs. of abandonment.
Signatu~tefti.6cd Well CO'o11ucfor or Woll Owner Date f f
By signing this form, I hereby certify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
lOa. Jlor All Well~: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. Fo•· Tnlectlon Wells: In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
tOe. Ftlr Water Supply & Inlcctlon 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 wei\ abandonment to the county health department of the county where
abandoned.
FormOW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
WELL CONSTRUCTION RECORD
This forrn can be used for single or multiple wells
1. Well Contractor lnfonnation:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well nse):
Water Supply Well:
OAgricultural DMunicipal/Public
OGeothennal (Heating/Cooling Supply) DResidential Water Supply (single)
Dlndustrial/Commercial O:R.esidential Water Supply (shared)
Olrrigation
Non-Water Supply Well:
0Monitoring DRecovery
Injection Well:
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) DOther (explain under#21 Remarks)
4. Date Well(s) Completed: 3/3/15 WeiiiD# OW4-90
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcelldentification No. (PIN)
Sb. Latitude and Long1tude tn degrees/mmutes/seconds or decJmal degrees:
(if well field, one !at/long is sufficient)
N 81.357202 -----------------35.419707 w
6. Is (are) the well(s): DPermanent or 121Temporary
7. Is this a repair to an existing well: DYes or l?lNo
g this is a repair, fill out known well construction infonnation and explain the nature of the
repair umkr #21 remarks section or on the back ofthisform.
8. Number of wells constructed: _1-:----:-:--:::-::=:---:--:-----
For multiple injection or non ... water supply wells ONLY with the yame coustruction, you can
submit one form.
9. Total well depth below land surface: Screen 61.58, Sand 63.00 (ft)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: 25.88 (24 hrs. after set) (ft)
if water level fs above casing. use .. +,
11. Borehole diameter: 8.5 (in.)
12. Well construction method: auger, rock core
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) -------Method of test:--------
OW4-9D I For Internal Use ONLY:
\
14. WATER ZONES .·· .·.·~. ' FROM TO DESCIUPTION
21.11 ft. 86.00 ft. Unconfined uppermost aquifer in soil
86.00 ft. 98.00 ft. Fractures in rock
·15. OUTER CASlNG for nmlti-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNEsS MATERIAL
ft. ft. in.
'l6.1NNER CASlNG ORTUBlNG (2eothennoil closed-loop) .· ·•
FROM TO DIAMETER THICKNESS MATERIAL
+3.00 ft. 51.58 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
:11. SCREEN· .. . ... · · ... ..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
51.58ft. 61.58 ft. 2 in. 0.01" Sch 40 PVC
ft. ft. in. 1/4" space
•18.GROUT ·: ... ·;.: ..
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >190 lbs. solids
3,63 ft. 48.5,~ft. Bent. Grout Tremie 250, 120 lbs. solids
48.5 ft. 50.5 ft. Bent. Chips Tremie 55 lbs. hydrated
.d9,SAND/GRA VEL PACK (if applicable) : .·· .· .··. ·:·
FROM TO MATERIAL EMPLACEMENT METHOD
50.5 ft. 63.0 ft. #2Silica Sand Tremie
86 ft. 98 ft. Bent. Chips Tremie 75 lbs. chips
20'. DRILLING LOG (atiach additionill.slieets if necessat:vl . · ·.
·····
FROM TO DESCRIPTION color, hardness" soil/rock, type, grain size, etc.
0.0 ft. 75 ft. SOIL; Residuum to saprolite, soft
75 ft. 86 ft. WEATHERED ROCK; More dense with dept
86 ft. 98 ft. ROCK;Gray, fractured, poor RQD
ft. ft.
ft. ft.
ft. ft. Abandoned lower part of boring 63'-98'
ft. ft. 2'X2' concrete pad with locked steel case
21. REMARKS ...
Observation well for hydrogeologic study for future Ph 4 LF
Deeper counterpart to adjacent nested well OW4-9S
3/30/15
Date
By signing this fonn, I h by certifY that the we/l(s) was (were) constructed in accordance
with 15A NCAC 02C .010 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where c:::..:.:===:.::~:..=======__.:.::::.::.::.::.:.========J constructed.
FortnGW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013
L:v\wh\ lor f.J\.SWLF
571(11 (tcu~e R.J
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--~--~--~-
•••••••••••••••••••
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OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
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G15041
DRAlllNG NO. SliEET NO.
8
WELL ABANDONMENT RECORD
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#: ---:----:-:c:-=-=------------:-:--List all applicable well construction permits (i.e. VIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
OAgricultural OMunicipal/Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
OindustriaVComrnercial OResidential Water Supply (shared)
0 Irrigation
Non-Water Supply Well:
II Monitoring ORecovery
Injection Wcl]:
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStormwater Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) DTracer
DGeothermal (Honting/CoolingReturn) OOther (explain under 7g)
4. Date well(s) abandoned: _6_1_3_11_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County
261897263
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one !at/long is sufficient)
35.420384 N 81.357907 --------------
CONSTRUCTION DETAJLS OF WELL(S) Dtl!lNGABANDONED
w
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.
6a. Well 10#: OW4-11 -----------
6b. Total well depth: _3_1_._6_5 ____ ,(rt.)
6c. Borehole diameter: _6_._5 _____ ,(ln.)
6d. Water level below ground surface: _1_9_._6_9 ______ .(ft.)
6e. Outer casing length (If known): _N_O_N_E _______ .(ft.)
6f. Inner casing/tubing length (if known): 21 · 65 (ft.)
6g. Screen length (If known): _1_5_. O_O ________ (ft.)
fntcmal Use ONLY:
\VELLABANDONMENTDETA~S
7a. For GeoprobeiDPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells nbnndoned:_, ______________ _
7b. Approximate volume of water remaining in well(s): _O ______ (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:----------------
7d. Amount of disinfectant used:--------------
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
II Bentonite Slurry
0 Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
0 Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard s gal slurry wl4o% active solids
7g. Provide a brief description of the abandonment procedure:
Sounded & vertfled total depth. Tremle grouted slurry under pressure from bottom up
while raising tremle pipe. Grouted to designed subgrade 9.62' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after> 2hrs. of abandonment.
8. ertlnc tl~
By signing this form, I hereby cerlify that the well(s) was (were) abandoned in
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.
9. Site diagram or additional well details:
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.
SUBN.UTTALINSTRUCTIONS
lOa. For All Well : Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. Jl'ur .lBiectlon Wclli: In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
lOc. For Water Sunnly & Inleetlon Well!: 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
abandoned.
FormGW-30 North Carolina Department of Environmental Quality· Division of Water Resources Revised 2-22-2016
WELL CONSTRUCTION RECORD
TIIis form can be used for single or multiple wells
1. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Nuoiber
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural OMunicipal!Public
OGeothermal (Heating/Cooling Supply) OResidential Water Supply (single)
DindustriaVCommercial OResidential Water Supply (shared)
Oirrigation
Non-Water Supply Well:
0Monitoring DRecovery
Injection Well:
OAquifer Recharge 0 Groundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test 0 Storm water Drainage
OExperimental Technology OSubsidence Control
OGeothermal (Closed Loop) OTracer
OGeothermal (Heating/Cooling Return) OOther (explain under #21 Remarks)
4. Date W ell(s) Completed: 3/20/15 WeliiD# QW4-11
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.420384 ------------------------N 81.357907 w
6. Is (ate) the well(s): OPermanent or 121Temporary
7. Is this a repair to an existing well: DYes or ~No
If this is a repair, fill out known well construction iriformation and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: _1-:---~---------------
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: Screen 31.65, Sand 32.00 (ft)
For multiple wells list all depths if different (example-3@200' and 2@1 00')
10. Static water level below top of casing: 22.69 (24 hrs. after set) (ft)
If water level is above casing, use "+"
11. Borehole diameter: 6.5 (in.)
12. Well construction method: _a_u~g_e_r _______________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) --------Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
19.69 ft. >32.00ft. Unconfined uppermost aquifer in soil
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM I TO I DIAMETER I THICKNESS I MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (e:eothermal closed-loop)
FROM TQ DIAMETER 'I'HICIQIESS MATERIAL
+3.00 ft. 16.65 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
16.65ft. 31.65 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >95 lbs. solids
3 ft. 13 ft. Bent. Grout Tremie 40 lbs. solids
13 ft. 15 ft. Bent. Chips Gravity 32 lbs. hydrated
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
15 ft. 32 ft. #2 Silica Sand Gravity
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft. 32 ft. SOIL; residuum to saprolite, mod. dense
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft. 2'X2' concrete pad with locked steel case
2l.REMARKS
Temporary observation well for hydrogeologic study
for future MSWLF Phase 4
3/30/15
Date
By signing this form, hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh; NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L:.:.:..=.::===:..::~:.:..::::;:::::;:::::;:::::;:::::;:::::;::=-..:.:==:::.:========-1 constructed.
FormGW-1 North Carolina Department of Environment and Natural Resources-Division ofWater Resources Revised August 2013
L:v,w\~\ Co~ rl\s·wL.F
5'2t9/ Crcu~e f{J
c f 0 u s e ;-J G 18: c ·3 3
--~--~--~-
•••••••••••••••••••
----810'---
----------250 --------__ , __ , __ ,_
OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
\
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G15041
DRAlllNG NO. SliEET NO.
8
WELL ABANDONMENT RECORD
I. Well Contractor Information: ---~ (.,_UJ •::z
Well Contractor Name (or well owner personally abandoning well on his/her property)
t.iZc..IO '3
NC Well Contractor Certification Number
Saedacco
Company Name
2. Well Construction Permit#:---,---------------
List all applicable well construction permits (i.e. U/C, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
DAgricultural DMunicipal/Public
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Dlndustrial/Commercial DResidential Water Supply (shared)
Dlrrigation
Non-Water Supply Well:
I!IMonitoring DRecovery
Injection Well:
DAquifer Recharge DGroundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control
DGeothermal (Closed Loop) DTracer
OGeotherma\ (Hcating/Coollng Return) OOther (explain under 7g)
4. Date well(s) abandoned: _6_1_3_11_6 ____ _
Sa. Well location:
Lincoln Co. MSWLF, Ph 4
Facility/Owner Name Facility ID# (ifapplicable)
5291 Crouse Rd. Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County
261897263
Parcel Identification No. (PIN)
Sb. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one laVlong is sufficient)
35.420391 N 81.357911 ---------------
CONSTRUCTION DETAILS OF WELL(Sl BEING ABANDONED
w
Attach well constn1ction record(s) if available. For multiple injection or non-water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: MW-34 ---------
6b. Total well depth: _3_2_._4_7 ____ (ft.)
6c. Borehole diameter: _6_._5 _____ (ln.)
6d. Water level below ground surface: _2_4_._7_3 ____ (.ft.)
6e. Outer casing length (If known): _N_O_N_E _____ (ft.)
6f. Inner casing/tubing length (If known): 17.4 7 (ft.)
6g. Screen length (If known): _1_5_._0_0 _______ (rt.)
I For Internal Use ONLY:
WELLABANDONMENTDETA~S
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only I GW-30 is needed. Indicate TOTAL NUMBER of
wells Jlbandoned:..,;1 ________________ _
0 7b. Approximate volume of water remaining in well(s): ______ .(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:-------------------
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout
D Sand Cement Grout
0 Concrete Grout
D Specialty Grout
1!!11 Bentonite Slurry
0 Bentonite Chips or Pellets
D Dry Clay
D Drill Cuttings
D Gravel
0 Other (explain under ?g)
7f. For each material selected above, provide amount of materials used:
Baroid Aquaguard 4 gal sluny w/40% active solids
7g. Provide a brief description of the abandonment procedure:
Sounded & verified total depth. Tremle grouted slurry under pressure from bottom up
while raising tremie pipe. Grouted to designed subgrade 13.23' bgs as required by
NCDEQ Solid Waste Section permit to construct.
Depth to grout verified after> 2hrs. of abandonment.
8.C~
Signature ofCnrliMtd Well Contractor or Well Owner Date( I
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Constn.lction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
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.
SUBMITTAL INSTRUCTIONS
lOa. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
lOb. Fol' Inlectlon Wells: In addition to sending the form to the address in lOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
tOe. For Water Supply & lo!ectlon Wells: In addition to sending the form to the
address(es) above, also submit on copy of this fonn within 30 days ofcmnplCltion
of well abandonment to the county health dcp(ll'lmcnl of the county where
abandoned.
FormGW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
--~--~--~-
•••••••••••••••••••
----810'---
----------250 --------__ , __ , __ ,_
OW4-11-0-
LEGEND
PROPOSED PHASE 4 WASTE LIMITS
ESTIMATED EXISTING WASTE LIMITS
CREEK
PROPOSED PHASE 4 SUBGRADE CONTOURS
EXISTING TOPOGRAPHIC CONTOURS
PROPERTY LINE (APPROXIMATE)
OBSERVATION / MONITORING WELL
TO BE ABANDONED
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G15041
DRAlllNG NO. SliEET NO.
8
WELL CONSTRUCTION RECORD
(OW-30)
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (pt·in Jay Little CERTIFICATION# 2717
WELL CONTRACTOR COMPANY NAME S&ME, Inc. PHONE# [phone]
STATE WELL CONSTRUCTION PERMIT# -------ASSOCIATED WQ PERMIT# _______ _
(if applicable) (if applicable)
1. WELL USE (Check Applicable Box): Residential D Municipal/Public 0 Industrial 0 Agricultral 0
Monitoring 0 Recovery 0 Heat Pump Water Injection D Other ~fOther, List Use observation well
2. WELLLOCATION:
Nearest Town: Crouse County _____ L_I_·n_co_l_n ____ _
Lincoln County Landfill
(Street Name, Numbers, Corrunmuty, Sudivision, LotNo.,Zip Code)
3. OWNER: Lincoln County Landfill
Address 5291 Crouse Road
(Street or Route No.)
Crouse NC 28033
City or Town State Zip Code
[phone]
Area code-Phone Nmnber
4. DATE DRILLED 12/21/2004 -----------5. TOTAL DEPTH 32
6. DOES WELL REPLACE EXISTING WELL? YES 0 NO/
7. STATIC WATER LEVEL Below Top of Casing: 23 .62 ft _ __:::..;:__ __ .
(Use"+" if Above Top of Casing)
8. TOP OF CASING 1S 2.95 FT. Above Land Surface*
*Top of casing terminated aUor below land surface requires a
variance in accordance with lSA NCAC 2C .0118.
9. YIELD (gpm) n/a METHOD OF TEST n/a ----10. WATER ZONES (depth): _______ __;_nl_a ______ _
11. DISINFECTION: Type n!a Amount n!a
12. CASING: Wall Thickness
Depth Dian1eter or Weight/Ft. Material
From 0 To 17 Ft. 2-inch Sch.40 PVC
From To Ft.
From To Ft.
13. GROUT: Depth Material Method
From 0 To 13 Ft. Neat Cement Pour ---From 13 To 15 Ft. Bentonite Pour
14. SCREEN: Depth Diameter Slot Size Material
From 17 To 32 Ft. 2-inch in. 0.01 in. PVC
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 15 To 32 Ft. #2 Silica Sand
From To Ft.
16. REMARKS:
Topographic/Land setting /
0 Ridge 0 Slope 0 Valley IY' Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude scource: OGPS OTopographic Map
(check box)
From
DEPTH
To
DRILLING LOG
Formation Descrpition
(see attached boring log) ---------
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads. Include the road
numbers and common names.
(see attached site map)
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Set·vice Center-Raleigh, NC
27699-1636 Phone No. [phone], within 30 days. GW-1 REV. 0712001
Well Construction Records
WELL CONSTRUCTION RECORD
This fonn can be used for single or multiple wells
1. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company N arne
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural DMunicipal!Public
OGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
0 Industrial/Commercial DResidential Water Supply (shared)
Olrrigation
Non-Water Supply Well:
IZIMonitoring DRecovery
Injection Well:
OAquifer Recharge 0 Groundwater Remediation
OAquifer Storage and Recovery 0 Salinity Barrier
OAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control
OGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) OOthet (explain under#21 Remarks)
4. Date Well(s) Completed: 3/23/15 Well ID# QW4-2
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35.419208 -------------------------N 81.355372 w
6. Is (are) the well(s): DPermanent or lilTemporary
7. Is this a repair to an existing well: DYes or ~No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the backofthisform.
8. Number of wells constructed: _1 ______________ _
For multiple injection or non-water supply wells ONLY with the same co1rstruction, you can
submit one form.
9. Total well depth belowlandsurface: Screen 30.78, Sand 31.50 (ft.)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: 21.01 (24 hrs. after set) (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: _a,_u:--g_e_r ____________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELlS ONLY:
13a. Yield (gpm) ________ Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
18.01 ft >31.5Qft. Unconfined uppermost aquifer in soil
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM I TO I DIAMETER I THICKNESS I MATERIAL
ft. ft in.
16. INNER CASING OR TUBING (~eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
+3.00 ft 15.78 ft. 2 in. Sch40 PVC flush thread
ft ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
15.78ft. 30.78 ft. 2 in. 0.01" Sch40 PVC
ft. ft in. 1/4" space
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0.0 ft. 3.0 ft Concrete Gravity >200 lbs. solids
3.0 ft. 12.0 ft. Bent. Grout Tremie 50 lbs. solids
12.0 ft 14.0 ft. Bent. Chips Gravity 55 lbs. hydrated
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
14.0 ft 31.5 ft. #2 Silica Sand Gravity
ft ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, h:u·dness, soil/rock type, gmin size, etc.)
0.0 ft 31.5 ft SOIL; Brown, soft
ft. ft
ft ft.
ft ft
ft. ft.
ft. ft
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Temporary observation well for hydrogeologic study
for future MSWLF Phase 4
22. Certification: ~~ Date
3/30/15
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L:::.:..::=:.==::.:~~=======_::::::::::..::========J constructed.
FormGW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 20 13
WELL CONSTRUCTION RECORD
This form oon be used for single or multiple wells I fO< Internal Usc ONLY:
I. Well Contractor Information:
John Thompson
WeU Cootraaor Name
3579-A
NC WeU Contractor Certification Nwnbcr·
Bluestone Environmental, LLC
Company Name
Z. Well Construction Permit#:
List a/1 applicable well petmlls (I.e. County, Stoll, Vari011ce,Jnjectlon, etcJ
3. Well Use (check well use):
Water Supply Well:
OAgricultural DMunicipai/Public
OGeothtllllal (Heating/Cooling Supply) OResidential Water Supply (single)
DindustriaVCommercial DResidential Water Supply (shared)
Olrrisration
Non-Water Supply Well:
IZIMonitoring ORecovery
injection Well:
CIAquifer Recharge OGroundwatcr Rem~-diation
OAquifer Storage and Recovery OSalinity Barrier
OAquifer Test OStonuwatcr Drainage
OExperimental Technology OSubsidence Control
DGeothermal (Closed Loop) DTracer
OGeothermal (HeatingfCooling Return) OOther (explain under /#21 Remarl<s)
4. Date Well(s) Completed: 3/23/15 Well ID# OW4-3S
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 {future)
Facility/Owner N111ne Facility !011 (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Pan:elldcnti.fieatiob No. (PIN)
Sb. Latitude and LoDgJtude In degrew nunnteslseeonds or decunal degrees:
(ifwcU field. one !at/long is sufficient)
_3_5_.4_18_4_2_9 ___ N 81 .35621 Q w
6. Is (are) the weU(s): OPnmanent or r;aTemporary
7. Is this a repair to an existing well: DYes or fnNo
If this is a rttpolt,fill out known well construclfon Information and uplain the nature of the
repair under 121 nmarks section or on the bock of this form.
8. Number of wells constructed: _1,........,.,-...,.,.=-,.....,..----
For multiple Injection or non-water supply wells ONLYwitlt tlte SIJJriiJ consfl"ucdon, you ca11
submit one form.
9. Tntal well depth below land sorf2Cle: Screen 45.95, Sand 46.50 (fL)
For multiple >rei/$ list all dtpthslf different (example-3@200' and 2@100')
10. Static water level below top of casing:~8.63 (24 hrs. after set) (fL)
(/water level Is above casing. we "+"
11. Borehole diameter: 8.5 (in.)
12. Well constroctioll method: _a_u,....:;g_e_r ___________ _
(i.e, auger, rotaty, cable, direct push, etc.)
FORWATERSUPPLYWELI.SONLY:
13a. Yield (gpm) ------=--Method oftest: -------
·14. WA:rERZONES·, ·. 1,• ··:· ' • •' .. ··. .. '• •• + '·
IIROM TO DESCRII"110N
35.82 ft. >46.50ft. Unconfined uppermost aquifer in soil
ft. ft.
:.tS.'OUTElt"CASJNG· for mulri-aied wdl'l OR-LINER if oppliuble ·. ~-•· . ··:
JROM TO DIAMF.TER THICKNESS MATERIAL
ft. ft. Ia.
16. INNER CASING OR TUBING (nothtnnal dosed,loou) c..-•• , . • .. ·
FROM TO DIAMJIT!!.l!. TmCICNESS .MATERIAL ..
+3.00 ft. 30.95 ft. 2 ln. Sch40 PVC flush thread
fl. fl. in.
17.SCREEN •,.• . '· -. .. · .. .. ,.;;.·;• .. -.·· .. :·. -~ ~
FROM TO DIAMETER SWTSIZE TRJCKNliSS MATERIAL
30.95ft. 45.95 ft. 2 in. 0.01" Sch 40 PVC
it. ft. ill. 1/4" space
IS. GROUT .,.· ... '·''. .-..... -. ..; •.•. ~ .. .. _,· ... ' .. •, ...
11ROM TO MATERIAL EMPLACEMENT MRTllOD & AMOUNT
0.0 Ct. 3.0 Ct. Concrete Gravity >190 lbs. solids
3.0 ft. 27.0 ft. Bent. Grout_ . Tremie 130 lbs. solids ·-·-. ~ . ---~ . --. . -· .. . . .....
27.0 ft. 29.50 fL Bent. Chips Gravity 65 lbs. hydrated
, •19. SAND/CRA VEL PACK If applicable ~~:. :'. :.• ~ . . . .... •':'· . ·.. . ...... .. . . ·,,.:_ .. ,
FROM TO MATERIAL l'.li!PLAC£MI'l>iTMETUOD
29.5 ft. 46.5 rt. #2Silica Sand Gravity
ft. ft.
~.:10.l>RILLTNG LOG attach ad'ditioaillshcetsifnec .. sary) · • .,,,~; .. ,, . :-~ .. '
FROM TO DESCRIPTION color,luoninw,soiVrock ..,..,rnok• alu, de.
0.0 ft. 42.0 ft. SOIL; Silty Sand, residuum, mod. density
42.0 ft. 46.5 ft. SOIL; Saprolite, more dense
ft. ft.
fL ft.
ft. ft.
ft. Ct.
ft. ft 2'X2' concrete pad with locked steel case
-~l:RRMARKS --' .. , .. ~~ >: . : .....
Observation well for hydrogeologic study for future Ph 4 LF
Shallower counterpart to adjacent nested well OW4-3D
3/30/15
Date
By signing th/$form, I hertby cerrify that lite well(s) wa.r (were) ronstructed in accordance
with /SA NCAC 02C .0100 or /SA NCAC 02C .0200 Well Construction Standatds and that a
copy of this record has been provided to the well owner.
23. Site dia~am or additional well detail$:
You may use lhe baclc of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUDMITT AL INSTUCI'IONS
24a. For All Wells: Submit this fonn within 30 days of completion of well
construction to lhe following:
Division of Water Resources, lnformatiou Processing Unit,
1617 Mall Serviu Center, Raleigh, NC 27699-1617
24b. For Injection Wellf ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Coutrol Program,
1636 MaU Service Center, Raleigh, NC 27699-1636
Z4c. For Water Supply & Iujeclion Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L.::::::=.:.::.:::=::...::~-======_..::=:.::.::.:..=======::..l constructed.
Form GW-1 North Carolina Department ofl!oviroruncot and Natural Rccources-Division ofWatc.r Resources Revised August20 13
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company N arne
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
Water Supply Well:
DAgricultural DMunicipal!Public
OGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Olndustrial/Commercial DResidential Water Supply (shared)
Dlrrigation
Non-Water Supply Well:
0Monitoring DRecovery
Injection Well:
DAquifer Recharge OGroundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology DSubsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 3/23/15 Well ID# OW4-6S
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.418803 N 81.357685 -----------------------w
6. Is (are) the well(s): DPermanent or 121Temporary
7. Is this a repair to an existing well: DYes or I!JNo
If this is a repair, fill out known well construction iriformation and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed: _1~~---------
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: Screen 32.05, Sand 32.50 (ft)
For multiple wells list all depths if different (example-3@200' and 2@1 00')
10. Static water level below top of casing: 23.29 (24 hrs. after set) (ft)
If water level is above casing, use "+"
11. Borehole diameter: 8.5 (in.)
12. Well construction method: _a_u:---g_e_r _____________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) -------Method of test:--------
14. WATER ZONES
FROM TO DESCRIPTION
20.29 ft. >32.50ft Unconfined uppermost aquifer in soil
ft. ft.
15. OUTER CASING (for multi~cased wells) OR LINER (if applicable)
FROM I TO I DIAMETER 1 miCKNEss I MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING (~eothermal closed~loop)
FROM TO DIAMETER THICKNESS MATERIAL
+3.00 ft. 17.05 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
17.05ft. 32.05 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18.GROUT
FROM TO MATERIAL EMPLACEMENT MEffiOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >190 lbs. solids
3 ft. 14 ft. Bent. Grout Tremie 60 lbs. solids
14 ft. 16 ft. Bent. Chips Gravity 55 lbs. hydrated
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT MEffiOD
16.0 ft. 32.5 ft. #2 Silica Sand Gravity
ft ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hat·dness, soil!t·ocll type, grain size, etc.)
0.0 ft. 22.0 ft SOIL; Silty Sand, residuum, soft
22.0 ft. 32.5 ft. SOIL; Saprolite, increasingly dense
ft. ft.
ft ft.
ft. ft.
ft. ft.
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Observation well for hydrogeologic study for future Ph 4 LF
Shallower counterpart to adjacent nested well OW4-6D
3/30/15
Date
By signing this form, I her by certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L.::.::..:.::.:===:...::~::..========-.:.:.::::=::..=========-1 constructed.
Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division ofWater Resources Revised August 2013
' ~\(0 i ~\ (o r {/1. 5 'W
5cl.{1/ Crouse f{J
c-rov~e ;\JG a.ac·-33
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
John Thompson
Well Contractor Name
3579-A
NC Well Contractor Certification Number
Bluestone Environmental, LLC
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural OMunicipal/Public
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
DlndustriaVCommercial DResidential Water Supply (shared)
Olrrigation
Non-Water Supply Well:
Iii Monitoring DRecovery
Injection Well:
DAquifer Recharge 0 Groundwater Remediation
DAquifer Storage and Recovery DSalinity Barrier
DAquifer Test DStormwater Drainage
DExperimental Technology OSubsidence Control
DGeothermal (Closed Loop) DTracer
DGeothermal (Heating/Cooling Return) 0 Other (explain under #21 Remarks)
4. Date Well(s) Completed: 2/25/15 Well ID# QW4-8
Sa. Well Location:
Lincoln Co MSWLF, Ph 4 (future)
Facility/Owner Name Facility ID# (if applicable)
5291 Crouse Rd Crouse NC 28033
Physical Address, City, and Zip
Lincoln 2691874263
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one )at/long is sufficient)
N 81.359375 ------------------------35.419216 w
6. Is (a.-e) the well(s): DPermanent or 121Temporary
7. Is this a repair to an existing well: DYes or IIINo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number ofwells constructed: _1 _________________ _
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: Screen 24.04, Sand 25.00 (ft}
For multiple wells list all depths if different (example-3@200' and 2@100') ,
10. Static water level below top of casing: 15.75 (24 hrs. after set) (ft)
If water level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: mud rotary, rock COre
(i.e. auger, rotary, cable, direct push, ~:tc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ________ Method of test: _______ _
14. WATER ZONES
FROM TO DESCRIPTION
12.75 ft. 47.00 ft. Unconfined uppermost aquifer in soil
47.00 ft. 75.00 ft. in slightly weathered and fractured rock
15. OUTER CASING (for multi-cased weDs) OR LINER (if applicable)
FROM I TO I DIAMETER I THICKNESS I MATERIAL
ft. ft. in.
16.1NNER CASING OR TUBING (2eothermal closed-loop)
FROM TO DIAMETER THlCKNESS MATERIAL
+3.00 ft. 9.04 ft. 2 in. Sch40 PVC flush thread
ft. ft. in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
9.04 ft. 24.04 ft. 2 in. 0.01" Sch40 PVC
ft. ft. in. 1/4" space
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0 ft. 3 ft. Concrete Gravity >260 lbs. solids
3,25 ft. 6,47 ft. Bent. Grout Tremie 10,60 lbs. solids
6,47 ft. 8,75 ft. Bent. Chips Tremie 28, 200 lbs. hydrated
19. SAND/GRAVEL PACK(ifapplicable)
FROM TO MATERIAL EMPLACEMENT METHOD
8.0 ft. 25.0 ft. #2 Silica Sand Gravity
ft. ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hru·dness, soil/rock type, grain size, etc.)
0 ft. 43 ft. SOIL; Silt residuum, soft
43 ft. 47 ft. Highly weathered rock; White, wet
47 ft. 75 ft. Rock; White, Very fractured, poor ROD
ft. ft.
ft. ft.
ft. ft. 25'-75' abandoned beneath well
ft. ft. 2'X2' concrete pad with locked steel case
21.REMARKS
Temporary observation well for hydrogeologic study
for future MSWLF Phase 4
3/30/15
Date
By signing this form, I ereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where L:.::.::...:.::::==:.::.:~:=======:.......:::.:::::.:::.::========J constructed.
FormGW-1 North Carolina Department ofEnvironment and Natural Resources-Division ofWater Resources Revised August 2013
L : 1\to \ ~\ (or N\ S W L. F
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