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Home My WebLink AboutAlamance_Well Abandonment_20220530 i WELL ABANDONMENT RECORD For Internal Use ONLY: 1.Well Contractor Information: WELL ABANDONMENT DETAILS Scott M. Werley 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW;30 is needed. Indicate TOTAL NUMBER of 3344-A wells abandoned:0- NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 3'O (gal.) ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY: Company Name - 7c.Type of disinfectant used:_ 2.Well Construction Permit#: N/A List all applicable well conshvction permits(i.e.UIC,County,State,Variance,etc)i(k 'nown R -- 7d.Amount of disinfectant used: 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that a 1 ❑Agricultural ❑Municipal/Public 11 Neat Cement Grout ( t ft�Sior Pellcts ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑IndustriaUCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings ❑Irri ation ❑ Specialty Grout ❑ Gravel Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g) RMonitoring El Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite - 40 Ibs ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Neat cement _ 40 Ibs ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity feed Bentonite chips from 20'-5' bgS Pour_neat cement from 5' bgs to ground surface 4.Date wells)abandoned: 5/4/2022 5a.Well location: Former Express 552 0-023879 Facility/Owner Name Facility ID#(if applicable) 8.Cen: 1845 North Church Street 5.19.2022 Physical Address,City,and Zip Signature of Certified We Co ractor or Well Owner Date Burlington ()1Q nap 139749 By signing this,%r•nt, I hereby certrJi•that the tcell(s) was (were) abandoned in County Parcel Identification No.(PIN) accordance ivith 15.4 AtCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy q%this record has been provided to the well owner. 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one[at/long is sufficient) 9.Site diagram or additional well details: 36.095071 N -79.406368 W You may use the back of this page to provide additional well site details or well abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attachivelfconstructionrecord(s)ijavailable. Fornmttipletnjectionornwi-�vatersapplvrvel/s ONLY with Ilse saute construction/abandonment,you can submit one jornn. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#• M W-1 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 20 (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: 8.25 (in) above, also submit one copy of this form within 30 days of completion of well abandonment to the following: 6d.Water level below ground surface: 11.10 (ft) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): N/A N/A 10c.For Water Supply&Infection Wells: In addition to sending the form to the ( address(es)above,also submit one copy of this form within 30 days of completion of well abandonment to the county health department of the county where 6f.Inner casing/tubing length(if known): 15 (ft.) abandoned. 6g.Screen length(if known): 5 (ft-) Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL ABANDONMENT RECORD For Internal Use ONLY: LL ABAND I.Well Contractor Information: WE ONMENT DETAILS Scott M. Werley 7a.For Geoprobe/DPTorClosed-Loop Geothermal Wells having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of 3344—A wells abandoned:c^e NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1'0 (gal) ECS Southeast, LLP FOR WATER SUPPLY WELLS ONLY: Company Name 7c.Type of disinfectant used: 2.Well Construction Permit#: N/A t•t"aC"U List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknown 7d.Amount of disinfectant used:_ 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(checgAbW yPraCz g url ❑Agricultural ❑Municipal/Public 11 Neat Cement Grout gkftf hips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay ❑Industrial/Cornmercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑Irrigation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g) RMonitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Bentonite — 20 Ibs ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage Neat cement — 40 Ibs ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Gravity feed bentonite chips from 20'-5' bgs ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Pour neat cement from 5' bgs to ground surface 4.Date well(s)abandoned: 5/4/2022 5a.Well location: Former Express 552 0-023879 , Facility/Owner Name Facility ID#(if applicable) 8.Certification: 1845 North Church Street 5.19.2022 Physical Address,City,and Zi Signature of Certified Contractor or Well Owner Date Burlington �u�_ 139749 6y signing this form, /hereby certi%y that the well(s) was(were) abandoned in County Parcel Identification No.(PIN) accordance with/SA NCAC 02C.0l00 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: o (ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details: 36.095071 N -79.406368 W You may use the back of this page to provide additional well site details or well abandonment details. You may also attach additional pages if necessary. CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS Attach nell construction record(s)ifavailable.For multiple injection ornon-watersupplywells 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-13 abandonment to the following: Division of Water Resources,Information Processing Unit, 6b.Total well depth: 20.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Iniection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter: 6.25 (in) above, also subunit one copy of this form within 30 days of completion of well abandonment to the following: 6d.Water level below ground surface: 13.62 (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Center,Raleigh,NC 27699-1636 fie.Outer casing length(if known): N/A N/A 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 6f.Inner casing/tubing length(if known): 10 (ft.) abandoned. 6g.Screen length(if known): 10 Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016