Granville_Well Abandonment_20220530

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
KEN NY SARGENT 7a.Number of wells being abandoned:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
construciion/abandomnent,you can submit one form.
A -4226
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 8'25 (gal.)
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLS ONLY: ���
Company Name 7c.Type of disinfectant used: INaCEIA
2.Well Construction Permit#: MAY 3 ® 2Q22
List all applicable ivell construction permits(I.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use check well use):
( ) 7e.Sealing materials used check all that apply):
Water Supply Well: g ( PP y)�
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets
❑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: El Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9.5 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage —
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA OVERDRILLING/GROUTED WITH TREMIE PIPE
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
AND BENTONITE SLURRY TO LANDFILL SUBGRADE ELEVATION
4.Date well(s)abandoned: 03/28/22
5a.Well location:
GRANVILLE COUNTY LANDFILL
Facility/Owner Name Facility ID#(if applicable) 8•Certification:
6584 LAND FILL ROAD OXFORD 27565 04/04/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
GRANVILLE By signing this form, I hereby certify that the well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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° 22' 15.04" 780 37' 00.72" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-tvater supply
wells ONLY udth the same cmnstructionlabandonment,you can submit one form 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: P-30D abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth' 58.5 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
2 0 above,also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: 8'0 (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (ft.) 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
6f.Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
I
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013