Granville_Well Abandonment_ (5)

WELL ABANDONMENT RECORD For Internal Use ONLY.
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy Joe Payne Jr 7a.For Geoprobe/DPT or Closed-L'oop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4532-B wells abandoned:
1
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): '6 (gal.)
Excel-SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name unknown Chlorination-Ca(OCI)2
7c.Type of disinfectant used:
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2.Well Construction Permit#: ,+�...C �i
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown -OZ i
7d.Amount of disinfectant used.
V D
3.Well use(check well use): 7
L
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public a Neat Cement Grout e Bent mte to r l�B&zz� q unk
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay OQ
❑hidustrial/Commercial ❑Residential Water Supply(shared) C Concrete Grout ❑Drill Cuttings
❑Irri ation ❑Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7E For each material'selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Neat Cement-8-lb Bentonite 30-lb
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage Concrete-8-lb
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal,(Closed Loop) ❑Tracer
Dropped Calcium Hypochorite tablet into well casing and
❑Geothermal(Heating/Cooling Return) []Other(explain under 7g)
filled casing with Bentonite pellets and poured neat cement
4.Datewell(s)abandoned: 04.25.2022 until approx. 1-tbgl and poured concrete inside casing to near the
5a.Well location: TOC and placed the lid on the manhole of the well.
Fast Fare NC-525
Facility/Owner Name Facility ID#(if applicable) 8.Ce tione
215 WILLIAMSBORO RD, Oxford NC, NC 27565 05.24.2022
Physical Address,City,and Zip Signature o •ertified Well tontractor r Well Owner Date
GRANVILLE 192313139147 By signing this form, I hereby certify that the well(s) was(were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 02C.0100 or 2C.0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.313160 N N - 78.566433 W `,l, You may use the'back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-10 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: —35.00' (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: —25.40' (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft,) 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): (ft.) abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016