Granville_Well Abandonment_ (17)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
D.T. Chalmers ,Jr. 7a.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
4146-A
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State, Pariance,etc)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 19 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) a Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —29lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete ^51bs
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Abandoned well in place with hydrated bentonite
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
pellets to within 6 inches of surface. Topped with
4.Date well(s)abandoned: 6/22/2022 concrete to existing grade.
Sa.Well location:
NCDEQ-Former Beacon Express 25 00-0-0000015085
Facility/Owner Name Facility ID#(if applicable) 8.Certification: Te 204 Broad St., Oxford 27565 6/29/2022
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville NA
By signing this forth, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 YVell Construction Standards
and that a copy of this record has been provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/long is sufficient) 9.Site diagram or additional well details:
36.312617 N -78.592295 W You may use the back of this page g.'r"'de,a#!c{itiogal lygl-si"etails or well
abandonment details. You may also tt01 $dgrtgt al�p'Sg ,a i ech4,y.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS (�
Attach well construction record(s)ifavailable.For multiple injection or non-water ivells J I J L 0 2022
ONLY with the sauce consiruclion/abandonwent,you can submit one•/orin.
10a. For All Wells: Submit this form within 30 days of co letion of well
6a.Well ID#: MW-4 abandonment to the following: OfYuGTR
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 18 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8.25 (in) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: NM (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
r 6e.Outer casing length(if known): NA 10c.For Water Suoaly&Iniection Wells: In addition to sending the form to the
(ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health depa;fineti f--the-c nth w��ere
6E Inner casing/tubing length(if known): 8 (ft) abandoned.
6g.Screen length(if known): 10 2022
(ft.)
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources
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