4403_FrancisFarm_WellAbandonmentInstallationReport_DIN26428_20160630

BUNNELL-LAMMONS ENGINEERING, INC.
GEOTECHNICAL, ENVIRONMENTAL AND CONSTRUCTION MATERIALS CONSULTANTS

REPORT OF MONITORING WELL
ABANDONMENT AND INSTALLATION
CLOSED FRANCIS FARM LANDFILL
HAYWOOD COUNTY, NORTH CAROLINA
PERMIT NUMBER 44-03
PREPARED FOR:

HAYWOOD COUNTY SOLID WASTE MANAGEMENT DEPARTMENT
CLYDE, NORTH CAROLINA PREPARED BY:
BUNNELL-LAMMONS ENGINEERING, INC.
GREENVILLE, SOUTH CAROLINA ASHEVILLE, NORTH CAROLINA
JUNE 30, 2016 BLE PROJECT NUMBER J15-1957-54

BUNNELL-LAMMONS ENGINEERING, INC.
GEOTECHNICAL, ENVIRONMENTAL AND CONSTRUCTION MATERIALS CONSULTANTS
6004 PONDERS COURT PHONE [phone] GREENVILLE, SOUTH CAROLINA 29615 FAX [phone]

June 30, 2016

North Carolina Department of Environmental Quality
Division of Waste Management – Solid Waste Section 1646 Mail Service Center
Raleigh, NC 27699-1646 Attention: Ms. Elizabeth S. Werner
Hydrogeologist Subject: Report of Monitoring Well Abandonment and Installation
Closed Francis Farm Landfill Haywood County, North Carolina BLE Project Number J15-1957-54
Permit Number 44-03
Dear Ms. Werner:
As authorized by Haywood County’s acceptance of our Proposal Number P15-0307 dated April 14,
2015 and on behalf of Haywood County, Bunnell-Lammons Engineering, Inc. (BLE) has performed
the required well adornment and installation services at the subject site. The purpose of the work was to abandon selected landfill gas monitoring and groundwater monitoring wells and to install landfill
gas monitoring wells as part of approved environmental monitoring plans for the subject site. The enclosed report describes the work performed and documents the well abandonments and installations as required.
BACKGROUND INFORMATION
The following project information was obtained from documents provided by Haywood County and from site data (in BLE’s project records) from our current services proposal with Haywood County.
Haywood County owns and maintains the Francis Farm Landfill which is currently closed (Figure 1). McGill Associates, P.A. (McGill) has been retained by Haywood County to provide engineering
services related to the post-closure care of the landfill. BLE has been retained by Haywood County (since 2007) to provide semi-annual statistical analysis and reporting services for groundwater and
surface water sampling conducted by others. Additionally, BLE has provided groundwater assessment
services which include installation and reporting of new groundwater monitoring wells installed as part of the ongoing Assessment of Corrective Measures (ACM).

The Francis Farm Landfill has 30 groundwater monitoring wells (MW-1A, MW-2A, MW-3A, MW-4 through MW-14, MW-14D, MW-15, MW-16, MW-16D, MW-17, MW-18, MW-19, MW-19D, MW-
20, MW-20D, MW-21, MW-23D and MW-22 through MW-25) and 4 surface water monitoring points (US-1, DS-1, DS-2, & DS-3) which are sampled every February and August. Landfill gas monitoring and reporting is also performed at the site as part of post-closure care. The Francis Farm Landfill has
Report of Well Abandonment and Installation June 30, 2016
Closed Francis Farm Landfill - Haywood County, North Carolina BLE Project Number J15-1957-54
2
13 landfill gas monitoring wells (MM-1 through MW-13) and 5 structure monitoring points (SM-1a,
SM-1b, SM-1c, SM-2, & SM-3) which are monitored quarterly in accordance with the facility plan.
Ongoing maintenance of the existing soil cap was conducted in 2015 and 2016 and permanent soil cap
improvements are pending as part of corrective measures planned for the site. Several of the existing
groundwater monitoring wells and landfill gas monitoring wells required abandonment and new landfill gas monitoring wells required installation as part of the improvements. A new Water Quality
Monitoring Plan (WQMP) and Landfill Gas Monitoring Plan (LFGMP) were prepared and submitted to the Solid Waste Section (SWS) in October 2015 by BLE to document planned changes to the facility’s monitoring infrastructure. The SWS approved the WQMP and LFGMP on November 25,
2015 (Document Identification Number [DIN] 25331). Each plan included specifications for well abandonment and installation.
BLE was retained by Haywood County to perform the well abandonment and installation services. This report describes the work performed and documents the well abandonment and installation as required.
SCOPE OF SERVICES PERFORMED

Landfill Gas and Groundwater Monitoring Well Abandonment
Ten (10) landfill gas monitoring wells (MM-1 through MM-6 and MM-10 through MM-13) and eight
(8) groundwater monitoring wells (MW-1, MW-1A, MW-2A, MW-3A, MW-4, MW-13, MW-14, and MW-14D) and were permanently abandoned at the subject site from December 9 through 17, 2015 (Tables 1 and 2).
Well abandonments were performed by a North Carolina licensed driller (Registration #3845-A) in
accordance with the approved plans. As part of the well abandonment procedures, the polyvinyl chloride
(PVC) casings and screens of the wells were removed by pulling from the ground surface using a winch or by other means. The resulting borehole at each former well location was then tremie grouted to the
ground surface with a cement-bentonite mixture. At well locations where the casing and screen could
not be removed, the well heads were undercut two feet and the resulting wells were grouted to the ground surface with a cement-bentonite mixture. In both cases the well pads and covers were removed and
disposed. Specific abandonment procedures for each well are documented on the Form GW-30 abandonment records (Appendix A).
Please note that the well symbols for the abandoned wells have been removed from the Water Quality and Landfill Gas Environmental Monitoring Systems (Figure 2) and their prior existence is referenced in the Historical Well Disposition section of the figure. A summary table of the revised landfill gas
monitoring system which includes 13 landfill gas monitoring wells and 5 structure monitoring points is provided on Table 1. A summary table of the revised groundwater monitoring system which includes the 23 remaining groundwater monitoring wells is provided on Table 2. A revised sampling matrix for
water quality is provided on Table 3.

Report of Well Abandonment and Installation June 30, 2016
Closed Francis Farm Landfill - Haywood County, North Carolina BLE Project Number J15-1957-54
3
Landfill Gas Monitoring Well Installation and Survey
BLE mobilized an ATV-mounted drill rig to install ten (10) landfill gas monitoring wells (MM-14 through MM-23) at the locations shown on Figure 2. Please note that the final well installation
locations were selected based on site conditions such as depth to water. Well installations were
performed by a North Carolina licensed driller (Registration #3845-A) in general accordance with the approved LFGMP and the SWS variance (DIN 25086). The wells were installed via hollow stem auger
from December 8 through 18, 2015. The ten new landfill gas monitoring wells’ location and elevation were surveyed by a North Carolina
registered land surveyor provided by McGill under direct contract with Haywood County. The survey data (Appendix B) was provided to BLE and was used to prepare Figure 2, the boring logs and well construction diagrams in Appendix C, the summary table of the revised landfill gas monitoring system
(Table 1), and the North Carolina (Form GW-1) well construction records (Appendix D).
CLOSING
We appreciate the opportunity to work with Haywood County, McGill, and the SWS on this project. If
the SWS has any questions or comments, please contact us at [phone].
Sincerely,
BUNNELL-LAMMONS ENGINEERING, INC.

Andrew W. Alexander, P.G., RSM Mark S. Preddy, P.G.
Senior Hydrogeologist Senior Hydrogeologist Registered, NC No. 1475 Registered, NC No. 1043

cc: Mr. David Francis – Haywood County Mr. Mark Cathey, P.E. – McGill Associates
Attachments: Tables 1 through 3 Figures 1 & 2 Appendices A through D e:\awa projects\mcgill\haywood county lf\1957-54 fflf well abandonment and install\fflf well abandon and install 1957-54 ble.docx

TABLES
Table 1
Landfill Gas Monitoring Well and Point Data
Closed Francis Farm Landfill
Haywood County, North Carolina
Permit Number 44-03
BLE Project No. J15-1957-54
Monitoring Point
Installation
Date
Well
Status/Purpose
Well Diameter
(in)Northing (feet)
Easting
(feet)
Lat. North
(dd)
Long. West
(dd)
Measureing Point
Elevation
Ground Surface
Elevation
Total Borehole
Depth (bgs)
MM-1 Oct-10 Abandoned December 2015
MM-2 Nov-10 Abandoned December 2015
MM-3 UK Abandoned December 2015
MM-4 UK Abandoned December 2015
MM-5 UK Abandoned December 2015
MM-6 UK Abandoned December 2015
MM-7 UK Compliance 1.0 661,595.86 822,699.27 UK UK 2740.61 2737.63 UK UK -UK UK -UK
MM-8 Sep-10 Compliance 2.0 661,342.80 822,426.37 UK UK 2756.58 2753.35 10.5 5.0 -10.0 2748.4 -2743.4
MM-9 UK Compliance 1.0 661,245.11 822,091.01 UK UK 2806.93 2803.88 UK UK -UK UK -UK
MM-10 Sep-10 Abandoned December 2015
MM-11 Sep-10 Abandoned December 2015
MM-12 Sep-10 Abandoned December 2015
MM-13 Sep-10 Abandoned December 2015
MM-14 Dec-15 Compliance 1.0 662,434.14 821,892.87 35.50558521 -82.95957833 2715.49 2712.50 20.2 5.0 -20.0 2707.5 -2692.5
MM-15 Dec-15 Compliance 1/4-inch 662,922.51 822,149.55 35.50695406 -82.95878198 *MPT*2615.89 2.6 2.0 -2.6 2613.9 -2613.3
MM-16 Dec-15 Compliance 1/4-inch 662,793.85 822,578.65 35.50664785 -82.95732404 *MPT*2622.16 2.3 1.7 -2.3 2620.5 -2619.9
MM-17 Dec-15 Compliance 1/4-inch 662,617.67 822,982.81 35.50620842 -82.95594352 *MPT*2620.57 2.0 1.4 -2.0 2619.2 -2618.6
MM-18 Dec-15 Compliance 1/4-inch 662,244.80 823,124.16 35.50520024 -82.95541905 *MPT*2624.31 2.0 1.4 -2.0 2622.9 -2622.3
MM-19 Dec-15 Compliance 1/4-inch 661,911.87 823,322.89 35.50430799 -82.95470727 *MPT*2631.05 2.0 1.4 -2.0 2629.6 -2629.0
MM-20 Dec-15 Compliance 1.0 661,425.06 823,191.48 35.50295716 -82.95508332 2664.47 2661.19 10.2 5.0 -10.0 2656.2 -2651.2
MM-21 Dec-15 Compliance 1.0 661,184.57 821,470.06 35.50210840 -82.96083038 2716.33 2716.64 45.2 5.0 -45.0 2711.6 -2671.6
MM-22 Dec-15 Compliance 1.0 661,587.71 821,238.61 35.50318980 -82.96166148 2679.16 2679.53 25.2 5.0 -25.0 2674.5 -2654.5
MM-23 Dec-15 Compliance 1.0 662,009.48 821,364.14 35.50436145 -82.96129655 2639.68 2639.83 20.2 5.0 -20.0 2634.8 -2619.8
SM-1a (Bus Garage)NA Compliance Structure UK UK UK UK NA NA NA NA -NA NA -NA
SM-1b (Bus Garage)NA Compliance Structure UK UK UK UK NA NA NA NA -NA NA -NA
SM-1c (Bus Garage)NA Compliance Structure UK UK UK UK NA NA NA NA -NA NA -NA
SM-2 (Equipment Storage)NA Compliance Structure UK UK UK UK NA NA NA NA -NA NA -NA
SM-3 (Maintenance Storage)NA Compliance Structure UK UK UK UK NA NA NA NA -NA NA -NA
Notes:
All survey data provided by McGill Associates, all units in feet.MM-1 through MM-7 & MM-9 installed by others.*MPT* - 1/4-inch tubing with quick connector coiled in well head vault.
All values shown to the nearest 0.1-ft have been rounded.MM-8 & MM-10 through MM-13 installed by BLE NA - Not applicable.
Measuring Point Elevation is top of casing.UK = Unknown, information is not available.Wells abandoned as part of cap improvements.
Screen Elevation
Screen
Depth (bgs)
E:\AWA Projects\McGill\Haywood County LF\1957-54 FFLF Well Abandonment and Install\Tables FFLF Well Inst and Abn 1957-54.xlsx
Prepared by: AWA
Checked by: IAI
Table 2
Groundwater Monitoring Well Data
Closed Francis Farm Landfill
Haywood County, North Carolina
Permit Number 44-03
BLE Project No. J15-1957-54
Well Northing Easting Lat. North Long. West Meas. Pt.Gnd. Surface Total Borehole Screen Well Well Top of Rock Top of
Well Location (feet)(feet)(dd)(dd)Elevation Elevation Depth (bgs)Depth (bgs)Type Monitors Depth (bgs)Rock Elev.
MW-1 Abandoned December 2015
MW-1A Abandoned December 2015
MW-2A Abandoned December 2015
MW-3A Abandoned December 2015
MW-4 Abandoned December 2015
MW-5 On-Site 661,286.31 822,167.91 35.502464177 82.958501150 2,797.08 2,797.37 94.0 73.1 -88.1 2,724.3 -2,709.3 II PWR 89.0 2,708.4
Groundwater Monitoring Wells MW-6 through MW-25 Installed by BLE
MW-6 Off-Site 662,941.12 822,167.78 35.507007166 82.958723254 2,612.63 2,613.03 12.5 2.3 -12.3 2,610.7 -2,600.7 II Res/Collv 12.5 2,600.5
MW-7 Off-Site 662,800.72 822,584.39 35.506667347 82.957305699 2,621.33 2,621.48 24.0 4.0 -19.0 2,617.5 -2,602.5 II Collv/Allv NE NE
MW-8 Off-Site 662,619.60 822,989.68 35.506214483 82.955920712 2,620.05 2,620.25 19.0 3.0 -13.0 2,617.3 -2,607.3 II Alluvial NE NE
MW-9 Off-Site 662,309.84 823,295.25 35.505397531 82.954853325 2,618.67 2,619.19 19.0 2.0 -12.0 2,617.2 -2,607.2 II Alluvial NE NE
MW-10 Off-Site 661,947.33 823,365.59 35.504410017 82.954568656 2,623.60 2,623.96 15.0 2.0 -12.0 2,622.0 -2,612.0 II Alluvial NE NE
MW-11 On-Site 661,509.39 822,572.73 35.503120939 82.957171928 2,756.22 2,756.46 100.0 70.8 -85.8 2,685.7 -2,670.7 II BR 71.0 2,685.5
MW-12 Off-Site 661,078.94 822,142.39 35.501892082 82.958559051 2,803.11 2,800.28 90.0 64.8 -79.8 2,735.5 -2,720.5 II BR 64.0 2,736.3
MW-13 Abandoned December 2015
MW-14 Abandoned December 2015
MW-14D Abandoned December 2015
MW-15 On-Site 662,338.59 821,896.86 35.505323343 82.959552125 2,719.57 2,716.89 163.0 75.8 -90.8 2,641.1 -2,626.1 II BR 19.0 2,697.9
MW-16 Off-Site 661,203.62 821,457.75 35.502159358 82.960874268 2,716.16 2,716.29 70.0 54.8 -69.8 2,661.5 -2,646.5 II PWR/BR 63.0 2,653.3
MW-16D Off-Site 661,192.49 821,467.73 35.502129896 82.960839270 2,716.28 2,716.57 150.0 116.0 -126.0 2,600.6 -2,590.6 II BR 81.0 2,635.6
MW-17 Off-Site 661,739.15 821,178.09 35.503598911 82.961884951 2,664.77 2,665.07 73.0 49.8 -64.8 2,615.3 -2,600.3 II PWR/BR 63.0 2,602.1
MW-18 Off-Site 662,150.91 821,256.31 35.504737902 82.961677540 2,620.91 2,620.93 41.0 25.8 -40.8 2,595.1 -2,580.1 II BR 22.0 2,598.9
MW-19 Off-Site 662,965.29 822,624.55 35.507123544 82.957192901 2,615.08 2,615.29 21.0 5.5 -20.5 2,609.8 -2,594.8 II Allv/Res NE NE
MW-19D Off-Site 662,952.84 822,617.92 35.507088639 82.957213494 2,615.33 2,615.62 59.0 53.9 -58.9 2,561.7 -2,556.7 II PWR NE NE
MW-20 Off-Site 661,973.29 823,503.41 35.504496365 82.954109418 2,621.94 2,622.13 15.5 5.3 -15.3 2,616.8 -2,606.8 II Alluvial NE NE
MW-20D Off-Site 661,973.43 823,494.68 35.504495795 82.954138746 2,621.94 2,622.12 69.0 60.0 -65.0 2,562.1 -2,557.1 II PWR NE NE
MW-21 Off-Site 661,424.40 823,203.28 35.502956636 82.955043604 2,658.37 2,658.72 36.0 18.8 -33.8 2,639.9 -2,624.9 II Residuum NE NE
MW-22 Off-Site 661,046.30 820,724.07 35.501647029 82.963316321 2,599.86 2,600.00 25.0 4.0 -24.0 2,596.0 -2,576.0 II Alluvial NE NE
MW-23 Off-Site 663,169.77 822,719.36 35.507695290 82.956901959 2,611.43 2,611.63 24.0 3.8 -23.8 2,607.8 -2,587.8 II Alluvial NE NE
MW-23D Off-Site 663,182.53 822,725.71 35.507731029 82.956882336 2,611.52 2,611.75 62.0 53.0 -58.0 2,558.8 -2,553.8 III BR 37.0 2,574.8
MW-24 Off-Site 662,019.81 823,641.42 35.504639177 82.953652291 2,625.80 2,626.04 35.0 7.5 -27.5 2,618.5 -2,598.5 II Collv/PWR/BR 15.0 2,611.0
MW-25 Off-Site 661,488.76 822,382.32 35.503043453 82.957808429 2,756.31 2,756.67 259.5 249.3 -259.3 2,507.4 -2,497.4 II BR 62.0 2,694.7
Notes:
All survey data provided by McGill Associates, all units in feet.NE = Not Encoutered BR & PWR = Bedrock & Partially Weathered Rock
All values shown to the nearest 0.1-ft have been rounded.Res = Residuum
MW-1, -1A, -2A, -3A, -4, -5 installed by others. MW-6 through MW-25 installed by BLE.Collv = Colluvium
Wells abandoned as part of cap improvements.Allv = Alluvium
Screen
Elevation
Table 2 GWM of Tables FFLF Well Inst and Abn 1957-54.xlsx
Prepared by: AWA
Checked by: IAI
Table 3
Sampling Matrix -- Water Quality
Closed Francis Farm Landfill
Haywood County, North Carolina
Permit Number 44-03
BLE Project No. J15-1957-54
February & August
Station ID
App II VOCs
EPA 8260
App I Total
Metals
EPA 6010
Pesticides
EPA 8081
Cyanide
SM 4500-CN-E
pH
Field
Sp. Cond.
Field
Temp.
Field
Ba
c
k
g
r
o
u
n
d

We
l
l
MW-12 X X X X X
MW-5 X X X X X X
MW-6 X X X X X X
MW-7 X X X X X X X
MW-8 X X X X X X
MW-9 X X X X X X
MW-10 X X X X X
MW-11 X X X X X X X
MW-15 X X X X X X
MW-16 X X X X X
MW-16D X X X X X
MW-17 X X X X X
MW-18 X X X X X
MW-19 X X X X X X
MW-19D X X X X X X
MW-20 X X X X X
MW-20D X X X X X
MW-21 X X X X X
MW-22 X X X X X
MW-23 X X X X X
MW-23D X X X X X
MW-24 X X X X X
MW-25 X X X X X X
US-1 X X X X X X X
DS-1 X X X X X X X
DS-2 X X X X X X X
DS-3 X X X X X X X
Leachate*Not Required Per Solid Waste Rules
Notes:
* A leachate collection system was not installed at the facility while the landfill was in operation.
* Landfill gas / leachate extraction wells were installed in 2011 as part of a landfill gas to energy system.
* Landfill leacahte is extracted on a intermitant basis and discharged to the POTW under permit.
* Landfill leacahte samples will only be collected if required by the POTW or if desired by the landfill operator.
Su
r
f
a
c
e
Wa
t
e
r
Le
a
c
h
a
t
e
E:\AWA Projects\McGill\Haywood County LF\1957-54 FFLF Well Abandonment and Install\Tables FFLF Well Inst and Abn 1957-54.xlsx
Prepared by: AWA
Checked by: MSP

FIGURES
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UNNAMED TRIBUTARY
BL
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B
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RATCLIFFE

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F
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(FL
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(

F
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(

F
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(

F
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(

F
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MW-5
MM-5
SM-1a
SM-3
SM-2
SM-1a SM-1b
RA
C
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N

C
R
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E
K
( FLOW)
MM-17
MM-16
MM-15
MM-23
MM-18
MM-19
MM-20
MM-22
MM-21
MM-9
SM-1c
MM-7
MM-8
MM-14
MW-25

APPENDICES

APPENDIX A
WELL ABANDONMENT RECORD GW-30 FORMS
FOR LANDFILL GAS AND GROUNDWATER MONITORING WELLS
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:







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









WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:







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
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









WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:









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









WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:





















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:





















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:









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









WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:





















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:




















WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1.Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2.Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3.Well use (check well use):
Water Supply Well:
Agricultural Municipal/Public
Geothermal (Heating/Cooling Supply)Residential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrigation
Non-Water Supply Well:
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier
Aquifer Test Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal (Closed Loop)Tracer
Geothermal (Heating/Cooling Return) Other (explain under 7g)
4. Date well(s) abandoned:
5a.Well location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
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):
Neat Cement Grout Bentonite Chips or Pellets
Sand Cement Grout Dry Clay
Concrete Grout Drill Cuttings
Specialty Grout Gravel
Bentonite Slurry Other (explain under 7g)
7f.For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8.Certification:
Signature of Certified Well Contractor or Well Owner Date
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
10a. 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
10b. For Injection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center,Raleigh, NC 27699-1636
10c.For Water Supply &Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
For Internal Use ONLY:





















APPENDIX B SURVEYOR’S REPORT (MCGILL ASSOCIATES)

APPENDIX C LANDFILL GAS MONITORING WELL CONSTRUCTION AND BORING LOGS
TOPSOIL
Brown, dry, fine to medium sandy SILT
Brown to yellowish-brown, dry, silty, fine to medium SAND
Brown to yellowish-brown, dry, silty, fine to coarse SAND
Brown to yellowish-brown, dry, silty, very fine to coarse
SAND
Auger refusal at 20.0 feet. No groundwater encountered at
time of drilling.
Bentonite cement, 0 to 1.5 feet
Bentonite seal, 1.5 to 4.0 feet
Filter pack, sand 4.0 to 20.0 feet
1-inch diameter, 0.010-inch slotted
Schedule 40 PVC well screen, 5.0 to
19.8 feet
Pipe cap
Total well depth, 20.0 feet
Total borehole depth, 20.0 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Aluminum stick-up with cover in a 3'
x 3' concrete pad and 4" steel
protective bollards (4)
Top of PVC casing elev. = 2,715.49
feet
Survey pin elev. = 2,712.50 feet
Northing = 662,434.14'
Easting = 821,892.87'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2710
2705
2700
2695
2690
2685
2680
2675
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-14
Sheet 1 of 1
12-15-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-14
START:12-15-15
2712.50ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL and vegetative organics
Brown, dry to slightly moist, fine to medium sandy SILT
Boring terminated at 2.6 feet. No groundwater encountered
at time of drilling.
Bentonite cement, 0 to 0.2 feet
Bentonite seal, 0.2 to 0.5 feet
Filter pack, sand 0.5 to 2.6 feet
1/4 inch diameter, stainless steel well
screen, 2.0 to 2.6 feet
Total well depth, 2.6 feet
Total borehole depth, 2.6 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad with 1/4 inch
tubing coiled in well head
Survey pin elev. = 2,615.89 feet
Northing = 662,922.51'
Easting = 822,149.55'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2615
2610
2605
2600
2595
2590
2585
2580
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-15
Sheet 1 of 1
12-10-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-15
START:12-8-15
2615.89ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL with GRASS
Brown, slightly moist, fine to medium sandy SILT -
(alluvium)
Boring terminated at 2.3 feet. No groundwater encountered
at time of drilling.
Bentonite cement, 0 to 0.1 foot
Bentonite seal, 0.1 to 0.5 feet
Filter pack, sand 0.5 to 2.3 feet
1/4-inch diameter stainless steel well
screen, 1.65 to 2.25 feet
Total well depth, 2.25 feet
Total borehole depth, 2.3 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad with 1/4 inch
tubing coiled in well head
Survey pin elev. = 2,622.16 feet
Northing = 662,793.85'
Easting = 822,578.65'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2620
2615
2610
2605
2600
2595
2590
2585
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-16
Sheet 1 of 1
12-10-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-16
START:12-8-15
2622.16ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL
Dark brown, dry, fine to medium sandy SILT - (alluvium)
Boring terminated at 2.0 feet. No groundwater encountered
at time of drilling.
Bentonite cement, 0 to 0.1 foot
Bentonite seal, 0.1 to 0.5 feet
Filter pack, sand 0.5 to 2.0 feet
1/4-inch diameter stainless steel well
screen, 1.4 to 2.0 feet
Total well depth, 2.0 feet
Total borehole depth, 2.0 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad with 1/4 inch
tubing coiled in well head
Survey pin elev. = 2,620.57 feet
Northing = 662,617.67'
Easting = 822,982.81'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2620
2615
2610
2605
2600
2595
2590
2585
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-17
Sheet 1 of 1
12-10-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-17
START:12-8-15
2620.57ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL with GRASS
Brown, dry, fine to medium sandy SILT - (alluvium)
Boring terminated at 2.0 feet. No groundwater encountered
at time of drilling.
Bentonite cement, 0 to 0.1 foot
Bentonite seal, 0.1 to 0.5 feet
Filter pack, sand 0.5 to 2.0 feet
1/4-inch diameter stainles steel well
screen, 1.4 to 2.0 feet
Total well depth, 2.0 feet
Total borehole depth, 2.0 feet
Borehole diamter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad with 1/4-inch
tubing coiled in well head
Survey pin elev. = 2,624.31 feet
Northing = 662,244.80'
Easting = 823,124.16'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2620
2615
2610
2605
2600
2595
2590
2585
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-18
Sheet 1 of 1
12-10-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-18
START:12-8-15
2624.31ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL with GRASS
Brown, dry, fine to medium sandy SILT - (alluvium)
Boring terminated at 2.0 feet. No groundwater encountered
at time of drilling.
Bentonite cement, 0 to 0.1 foot
Bentonite seal, 0.1 to 0.5 feet
Filter pack, sand 0.5 to 2.0 feet
1/4-inch diameter stainless steel well
screen, 1.4 to 2.0 feet
Total well depth, 2.0 feet
Total borehole depth, 2.0 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad with 1/4-inch
tubing coiled in well head
Survey pin elev. = 2,631.05 feet
Northing = 661,911.87'
Easting = 823,322.89'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2630
2625
2620
2615
2610
2605
2600
2595
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-19
Sheet 1 of 1
12-10-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-19
START:12-8-15
2631.05ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL with organics
Dark brown, dry, fine to medium sandy SILT
Brown, dry, fine to medium sandy SILT
Boring terminated at 10.0 feet. No groundwater
encountered at time of drilling.
Bentonite cement, 0 to 1.5 feet
Bentonite seal, 1.5 to 4.0 feet
Filter pack, sand 4.0 to 10.0 feet
1-inch diameter, 0.010-inch slotted
Schedule 40 PVC well screen, 5.0 to
9.8 feet
Pipe cap
Total well depth, 10.0 feet
Total borehole depth, 10.0 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Aluminum stick-up with cover in a 3'
x 3' concrete pad with 4-inch steel
protecive bollards (4)
Top of PVC casing elev. = 2,664.47
feet
Survey pin elev. = 2,661.19 feet
Northing = 661,425.06'
Easting = 823,191.48'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2660
2655
2650
2645
2640
2635
2630
2625
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-20
Sheet 1 of 1
12-10-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-20
START:12-9-15
2661.19ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
0.5-feet of ASPHALT and BASE COURSE
Brown, dry, silty, fine to medium SAND
Brown to yellowish-brown, dry, slightly micaceous, silty,
very fine to medium SAND
Yellowish-brown, dry, silty, fine to medium SAND
Brown, dry, slightly micaceous, silty, fine to medium SAND
Brown to tannish-brown, micaceous, silty, fine to medium
SAND
Bentonite cement, 0 to 1.0 foot
Bentonite seal, 1.0 to 4.0 feet
Filter pack, sand 4.0 to 45.0 feet
1-inch diameter, 0.010-inch slotted
Schedule 40 PVC well screen, 5.0 to
44.8 feet
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2715
2710
2705
2700
2695
2690
2685
2680
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-21
Sheet 1 of 2
12-17-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-21
START:12-16-15
2716.64ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
Brown to tan and brown, micaceous, silty, fine to medium
SAND
Boring terminated at 45.0 feet. No groundwater
encountered at time of drilling.
Filter pack, sand 4.0 to 45.0 feet
1-inch diameter, 0.010-inch slotted
Schedule 40 PVC well screen, 5.0 to
44.8 feet
Pipe cap
Total well depth, 45.0 feet
Total borehole depth, 45.0 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad
Top of PVC casing elev = 2,716.33
feet
Survey pin elev. = 2,716.64 feet
Northing = 661,184.57'
Easting = 821,470.06'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2675
2670
2665
2660
2655
2650
2645
2640
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-21
Sheet 2 of 2
12-17-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
45
50
55
60
65
70
75
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-21
START:12-16-15
2716.64ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
1-foot of ASPHALT and BASE COURSE
Brown, dry, fine to medium sandy SILT
Brown to yellowish-brown, dry, silty, very fine to medium
SAND
Brown to yellowish-brown, dry, silty, fine to medium SAND
Boring terminated at 26.0 feet. No groundwater
encountered at time of drilling.
Bentonite cement, 0 to 0.8 feet
Bentonite seal, 0.8 to 4.0 feet
Filter pack, sand 4.0 to 26.0 feet
1-inch diameter, 0.010-inch slotted
Schedule 40 PVC well screen, 5.0 to
25.2 feet
Pipe cap
Total well depth, 25.4 feet
Total borehole depth, 26.0 feet
Borehole diameter. 6.0-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad
Top of PVC casing elev. = 2,679.16
feet
Survey pin elev. = 2,679.53 feet
Northing = 661,587.71'
Easting = 821,238.61'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2675
2670
2665
2660
2655
2650
2645
2640
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-22
Sheet 1 of 1
12-18-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-22
START:12-15-15
2679.53ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS
TOPSOIL and GRASS
Brown to yellowish-brown, dry, silty, fine to medium SAND
Yellowish-brown, dry, slightly micaceous, silty, medium to
coarse SAND with gravel
Brown to yellowish-brown, dry, silty, fine to medium SAND
Boring terminated at 20.0 feet. No groundwater
encountered at time of drilling.
Bentonite cement, 0 to 0.4 feet
Bentonite seal, 0.4 to 4.0 feet
Filter pack, sand 4.0 to 20.0 feet
1-inch diameter, 0.010-inch slotted
Schedule 40 PVC well screen, 5.0 to
19.8 feet
Pipe cap
Total well depth, 20.0 feet
Total borehole depth, 20.0 feet
Borehole diameter, 6-inches
SURFACE COMPLETION
Flush-mount secured with an 8-inch
diameter steel bolted manhole cover
in a 3' x 3' concrete pad
Top of PVC casing elev. = 2,639.68
feet
Survey pin elev. = 2,639.83 feet
Northing = 662,009.48'
Easting = 821,364.14'
DESCRIPTION
LOCATION:
DRILLER:
DRILLING METHOD:
2635
2630
2625
2620
2615
2610
2605
CAVING>
LANDFILL GAS MONITORING WELL NO. MM-23
Sheet 1 of 1
12-17-15
DEPTH TO - WATER> INITIAL:
CLIENT:
PROJECT NO.:
END:Haywood County
Haywood County, North Carolina
Landprobe, J. Gorman
ELEVATION/
DEPTH (FT)
5
10
15
20
25
30
35
PROJECT:
CME 75; 3-1/4 inch ID hollow stem auger
J15-1957-54
AFTER 24 HOURS:
LANDFILL GAS MONITORING WELL NO. MM-23
START:12-15-15
2639.83ELEVATION:
I. IrizarryLOGGED BY:
Francis Farm Landfill
GE
O
T
_
W
E
L
L
N
B

1
9
5
7
-
5
4
.
G
P
J

6
/
2
9
/
1
6
SOIL
TYPE
WELL INSTALLATION
DETAILS

APPENDIX D
WELL CONSTRUCTION RECORD GW-1 FORMS
FOR LANDFILL GAS MONITORING WELLS