Granville_Well Abandonment_ (13)

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 same
construction/abandonment,you can submi(owe form.
A -4226 175
7b.Approximate volume of water t•em .
aining in well(s): (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: _
f
2.Well Construction Permit#: r r �✓�.
List all applicable tivell construction permits(i.e.County,State,Variance,etc.)ifknown 7d.Amount of disinfectant used
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all th**xpty,i,t+aq hfp%,-yphn UR>i
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑ BentQr�f 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: IZI Bentonite Slurry ❑Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 3.0 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
El Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
AND BENTONITE SLURRY TO IANDFILL SUBGRADE ELEVATION
4.Date well(s)abandoned: 03/28/22
t
5a.Well location:
GRANVILLE COUNTY LANDFILL
Facility/Owner Name Facility ID4(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 fonn, I hereby certify that lire well(s)was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A 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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
22 15.46' 78 37' 10.36 You may use the back of this page to provide additional well site details or well
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e 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 ONLYwith the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this fox-in within 30 days of completion of well
6a.Well ID#: P-33S abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
19.0 1617 Mail Service Center,Raleigh,NC 27699-1617
(ft.)
10b.For Injection 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
6e.Borehole diameter: 2'0 (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: $'� (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Injection 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.
GE Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): (ft.)
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Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013