Granville_Well Abandonment_ (21)

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
4146-A wells abandoned:
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.(IIC,County,State,Variance,etc.)ifiknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Scaling materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 9 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: El Bentonite Slurry B 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
❑Aquifer Test ❑Stormwater Drainage Topsoil ^51bs
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer Pulled well completley and backfilled with h drated
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
bentonite pellets to within 6sinc, s fps , 'cet
4.Date well(s)abandoned: 6/22/2022 Topped with topsoil to existing,. r
5a.Well location:
NCDEQ-Former Beacon Express 25 00-0-0000015085
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: tl/x- e3V111
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 form, I hereby certify th F 1)t;'rr�lli'(s,��riau9�jii a an�loned in
County Parcel Identification No.(PIN) accordance it,ith 15A NCAC 02C.0100 or 2°C'`�2oQ IYd'lYCorish ttc►ioM;4tandards
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provide thwei� ,J�� � �o 2
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
36.312411 -78.592269 You may use the back of this page toltead�itioli ill•ABiIC4ite�de�t�is or well
N W abandonment details. You may also attach add iti&iu'(`p'�tg''t�Checessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach trell constrnctibt recoi•d(v)ifarailable.Fmvnuttiple injection or ton-u•ater.sttpply wells
ONLY with the same constructionlabandoninent,you can submit one fibrin.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#• MW-1 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 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 fort 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) 10c.For Water Supply&Infection 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 department of the county where
6E Inner casing/tubing length(if known): 8 (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016