Granville_Well Abandonment_ (18)

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,1/1C,County,State, Variance,etc.)it known
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 ®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
❑Irri ation ❑ 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 ❑GroundwaterRemediation Bentonite Pellets —29lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
Concrete —51bs
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Abandoned well in place with hydrated Bentonite
pellets to within 6 inches of surface. Topped with
4.Date well(s)abandoned: 6/22/2022
concrete to existing grade.
5a.Well location:
NCDEQ-Former Beacon Express 25 00-0-0000015085
Facility/Owner Name Facility lD#(ifapplicable) 8.Certification: �%'� .
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 d t;tllyl ) ttvay Fv,� oned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2C.0200 lt elt�oV'stAtuN3n,8tandards
and that a copy of this record has been providye I well g
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: tl// ! 20�t
(if well field,one lat/long is sufficient) 9.Site diagram or additional well d ,,'.
36.312416 N -78.592575 `� You may use the back of this page to pr vidi ffli dnaMvktl�tte(dKpils or well
abandonment details. You may also attach additfon24giagefnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach ravell construction record(s)ifavailable.For multiple injection ornon-uatersupplrwells
ONLY with the same cmtrtrmction/abandonment,von can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-5 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b..Total well depth: 18 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Iniection 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
6e.Outer casing length(if known): NA (ft.) loc.For Water Supply&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the county health depart end of t'the county whe
abandoned.
6E Inner casing/tubing length(if known): $ 4 n I 9
6g.Screen length(if known): 10 02?
min v f 4:Br•
Form GW-30 North Carolina Department of E t nvironmenal Quality vision oaer Resources
r''Revised'2QZ2 r 0,1 G.;"
P Q ty-Di of Water R tru l:,•;vcti'Sl ii�;%,i"i �i�:',;vt.11