Lee_Well Abandonment_20220708

WELL ABANDONMENT RECORD For Internal Use ONLY:
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1.Well Contractor Information: WELL ABANDONMENT DETAILS
Morey D. Futral 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
4330-B wells abandoned: l I
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
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CATLIN Engineers and Scientist 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.Counm,State,Gariance,e1c.)ifknown
7d.Amount of disinfectant used:
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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) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑ Bentonite Slurry e Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7C For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Native Material k —92lbs
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
t +
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ootner(explain under 7g) Completely pulled well and filled with native material
while excavating occurred.
4.Date well(s)abandoned: 6/28/2022 e ",6Z k—"C s V C LJ
5a.Well location: J IJ L 0 S 2022
NCDECI-Former N. P. Sloan Inc 00-0-014927
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: , PrIIyz�aingUnA
217 N. 11th St, Sanford, 27330 ib :1QI C 7/
7/1/2022
Physical Address,City,and Zip Signature of Certified Well Contractor!or Well Owner Date
Lee NA
By signing this form, I hereby certify that the well(s) ivas (were) abandoned in
County Parcel Identification No.(PIN) accordance with I5A 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:
(if well field,one lat/long is sufficient)
9.Site diagram or additional well details:
35.487193 o N -79.161484 W You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifm ailable.For multiple injection or non-watersupply wells
ONLY with the same construction'ahandonment,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,
30 1617 Mail Service!Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
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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:
10 (ft.) Division of Water Resources;Underground Injection Control Program,
1636 Mail ServiceiCenter,Raleigh,NC 27699-1636
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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
abandoned.
6f.inner casing/tubing length(if known): 15 (ft.) a �
t
6g.Screen length(if known): 15
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Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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® MW-64 I
FORMER MW-2
4,000-GAL.
DIESEL UST
MW-7 MW-5 _ CNL
I )
MW-4 FORMER-
550-GAL.
US7— I
FORMER550-GAS "— I
GASO I 'US,
MW-1 1
MW-8 ® MW-10
LEGEND 1
1
® Abandoned Monitoring FORMER 5,000-GAL.
GASOLINE/DIESEL UST �i 1
Well (Type II) 1
Monitoring Well ® MW-9 1
® (Type II)
Water Lines
1
Buried a 1� S
Buried Sewer Lines 1
y
Buried Natural Gas Lines
Buried Phone Lines 16,
Overhead Power Lines
Approximate Location j
of Former UST System
Parcel Boundary
Source: Esri,Maxar, Earthstar Geographics.and the GIS User Community
NOTES:
1. Well and tank locations were obtained from previous reports 40 20 0 40 80
prepared by other consultants and are approximate.
Feet
2. CNL=Could Not Locate
PROJECT TITLE FIGURE
FORMER NP SLOAN INC
ATLIN 217 N 11TH ST SITE MAP
CSANFORD, NC 1
Engineers and Scientists
INCIDENT NO. JOB NO DATE SCALE I DRAWN BY/CHECKED BY
15981 221068 JULY 2022 AS SHOWN KMC/BJA