Granville_Well Abandonment_ (6)

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: 1
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple h jection or non-ivater supply wells ONLY with the same
A -4226 constructionlabandonment,you can submit one form.
7b.Approximate volume of water remaining in well(s): 2'75 (gal.)
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION/ INC FOR WATER SUPPLY WELLS ONLY: ..,
Company Name 7c.Type of disinfectant used: !
2.Well Construction Permit#: MAY 3 0 2�22
List all applicable well construction permits(i.e.County,State,Variance,etc.)iflotoum 7d.Amount of disinfectant used:
a
3.Well use(check well use): Qj~p •tiJ flit
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
❑htdustriaVCommercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry ❑Other(explain under 7g)
El Monitoring ❑Recovery
Injection Well 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 4.0 GALLONS
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonmefit procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA OVERDRIL.LING/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 cerir,'fy that the well(s)was (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A NCAC 01C.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:
22 16.45' 78e 37 08.2$ 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 WEI.L(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Auach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construcaonlabandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• P-6 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 25.5 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection 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 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
611 Inner casing/tubing length(if known): (ft.) where abandoned.
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
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