Chatham_Well Abandonment_ (5)

WELL ABANDONMENT RECORD For Intern aI Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Billy J. Payne 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
4532-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): —3.5 (gal.)
Excel Civil and Environmental Associates/SRP Environmental FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: Chlorination-Ca(OCI)2
2.Well Construction Permit#: Chatham Co.Public Health hasn't hasn't issued permit number yet.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)if known 3-oz.
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 S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑IndustriaVCommercial ❑Residential Water Supply(shared) S Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
SMonitoring ❑Recovery
Injection Well: C`` For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundW[REC IVEaoncrete 10 lb
❑Aquifer Storage and Recovery ❑Salinity Barrie I q
❑Aquifer Test ❑StormwaterD7l Wage` 2 2022 Bentonite Pellets 27 lb (+/-)
❑Experimental Technology ❑Subside p"n
� g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
One 3-oz tablet of chlorine disinfectant tablet was dropped into
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
the bottom of the 2"riser well&Bentonite pellets were poured
4.Date well(s)abandoned: 06/22/2022 into the wells to near the TOC&Concrete Grout was tremied
5a.Well location: into the wells to above the TOC&manhole lid placed on top.
(Former) Servco Pittsboro 0-00-007595
Facility/Owner Name Facility ID#(if applicable) S.Ce ation:
471 Hillsboro Street., Pittsboro NC 27312 7-19-2022
Physical Address,City,and Zip Si a ure of Cert'het4om..tar or Well Owner Date
Chatham 8187
By signing this fonn, 1 hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) accordance with 1 SA 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: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
350 43' 37.6104" N -790 10' 36.285" 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)ifavailable.For multiple injection or non-1vatersupply wells
ONLY with the same construction/abandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: M W-3 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: — 50 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6"Outer/2"Inner above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
6d.Water level below ground surface: — 28 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known): — 0-26 (ft.) 10c.For Water Supply&Injection 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
6f.Inner casing/tubing length(if known): — 22-30 (ft) abandoned.
6g.Screen length(if known): 30' - 50'=20 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016