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HomeMy WebLinkAboutGranville_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