Granville_Well Abandonment_ (7)

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 ofwells being abandol ed:
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY ivith the same
constructioniabandonmem,you can submit one form.
A -4226 ' - 7.75
NC Well Contractor Certification Number I
7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION,INC FOR WATER SUPPLY WELLS(ONLY: ;�
Ft CEO
Company Name7c.Type of disinfectant used: A
2.Well Construction Permit#: MAY 3 © 2022
List all applicable well construction permits(t.e.County,State,Variance,etc.)i#'known 7d.Amount of disinfectant used:
'1
3.Well use check well use): G1�' rkq
( ) 7e.Sealing materials used(check all that apply): Q/HOC
"
Water Supply Well:
❑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: 0 Bentonite Slurry ❑ Other(explain under 7g)
OMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation 9.0 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
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
AND BENTONITE SLURRY TO LANDFILL SUBGRADE ELEVATION
4.Date well(s)abandoned: 03/28/22
5a.iVell location: -
GRANVILLE COUNTY LANDFILL
Facility/Owner Name Facility ID#(ifapplicable) $•Certification:
6584 LAND FILL ROAD OXFORD 27565 Ur1t�► � � .•�- 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 ivell(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:
36 22 10.40 780 �37 03.22 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 ivell construction record(s)if available. For multiple injection or non-water supply
wells ONLY Wilt the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• P-1 2 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth: 55.0 (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
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