Granville_Well Abandonment_ (9)

WELL ABANDONMENT RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
KENNY SARGENT 7a.Number of wells being abandoned: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the saute
construction✓abandonment,you can submit one form.
A - 4226
7b.Approximate volume of water remaining in well(s): 4'S
(gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC FOR WATER SUPPLY WELLft
S
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used: Llrlil
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
ElMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation 5.75 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
5%Well location:
GRANVILLE COUNTY LANDFILL
Facility/Owner Name Facility ID#(if applicable) g•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 fonn, I hereby certify that the well(s)was (were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0i00 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
22 15.07 7$e 37 00.78 You may use the back of this page to provide additional well site details or well
36
o " N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)if available. For multiple injection or non-water supply
wells ONLY with the same cmtstruction/abandmtntent,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
P-30S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.1'ol:tl well depth:
35.0 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection 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
6c.Borehole diameter: 2'0 (in.) abandonment to the following:
6d.Water level below ground surface 8.0 (ft.) Division of Water Quality,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Suaaiv&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
Where abandoned.
6f.Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources.—Division of Water Quality Revised March 2013