Granville_Well Abandonment_20220701 (2)

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.U/C,County,State, Variance,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 C 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 111 Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —350lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwa ter Drainage
Concrete/Topsoil ^401bs —51bs
❑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), Pulled vault and abandoned well in place with
hydrated bentonite pellets to within 6 inches
4.Date well(s)abandoned: 6/22/2022 of surface. Topped with concrete and topsoil
5a.Well location: to existing grade.
NCDEQ-Former Beacon Express 25 00-0-0000015085
Facility/Owner Name Facility ID/!(if applicable) 8.Certification:204 Broad St., Oxford 27565 y� 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 that the tve11(s) was (here) abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100 or 2�2UD iir11�ronsfutct;Qdt�Standaids
and that a copy of this record has been provisedr16-I '%q1-ooYrYe} .
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: JUL
36.312403 N -78.592264 W You may use the back of this page to provide add f ona "Al Mgails or well
abandonment details. You may also attachh��c���figottqt,"pes if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED �tCtli'.�;7L;
SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifm,ailable.For nudtiple ityection at,non-iraler supply welis
ONLY with the same convirrrctiom/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: RW-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 25 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b. For Injection 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): Unknown (ft.) 10c.For Water Suaaly&Iniection Wells: In addition to sending the form to the
address(es)above,also submit one copy of this form ithin 30 days of completion
of well abandonment to the county health Oeparti ent Ftthe county'•where
Unknown abandoned. ` �='K .• ` v1�1'—Ir �
6E Inner casing/tubing length(if known): (ft.)
6g.Screen length(if known): Unknown (ft.) jU� -
e4t Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources 16
;;?- oni Y.�r' '•'Rs�8 2 22-20

APPROXIMATE LOC ".,�11..
OF GROUNDWATER'�"�
0 TREATMENT SYSTEM N
3,000-GAL.
GASOLINE
a A CURRENT BASIN
OF THREE
8,000-GAL. LISTS
MW-4
r .r' DISPENSER ,BMW-2
ISLANDS
~ RW-1 0 >
2!000-GAL.
6,000-GAL. DIESEL UST
GASOLINE 2,000-GAL.
UST GASOLINE
UST
MW-1
MW-5" RW-3 '
® MW-3 4
LEGEND
RW-2 '
® Monitoring Well
(Type II) �"" �S(
® Destroyed Monitoring • '' P�P�P
Well (Type II) G�
G
0 Recovery Well
0 Approximate Location
of UST System 'CW.
0 Approximate Location
of Current UST Basin MW-6
0 Parcel Boundary
Source:Esh,Makar, Earthstar Geographics'and the
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Feet
PROJECT TITLE
FORMER BEACON FIGURE
ATLIN EXPRESS 25 SITE MAP
204 BROAD ST
Engineers and Scientists OXFORD, NC
INCIDENT N0. JOB N0. DATE SCALE DRAWN BY/CHECKED BY
5111 222012 JUNE 2022 AS SHOWN KMCISJO