Johnston_Well Abandonment_20220729

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WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single and multiple wells
1.Well Contractor Information WELL ABANDONMENT DETAILS
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Well Contractor Name:Gary A Fischer 7a.Number of wells being abandoned:1
Well Contractor Certification:3339
For multiple injection or non water supply wells ONLY with same
Company Name:Md-Atlantic Assoc.
contruction abandonment.you can submit one form.
2.Well Construction Permit#: 7b.Approximate volume of water remaining in well(s):0.00(gal.)
3.Well use(check well use)
Water Supply Well: FOR WATER SUPPLY ELLS ONLY
❑Agricultural ❑ Municipal/Public 7c.Type of disinfectant used:
❑ Geothermal ❑ Residential Water Supply(single) 7d.Arnont of disinfectant used;:
❑Industrial/Commercial ❑ Residential water Supply(shared) !
❑Irrigation 7e.Sealing materials used:Neat Cement Grout
Non Water Supply Well: 7f.For each material selected above,provide amount of material
I-� used:7.0 gals.Water 35 lbs.Type 1 Portland cement.3 lbs.
KJ Monitoring ❑Recovery powdered bentonite
Injection Well: 7g.Provide a brief description of the abandonment procedure:
❑Aquifer Recharge ❑ GroundveterRemediation Put a 1"pvc tremmie pipe down the well to the bottom.Poured neat
cement thru a funnel down the tremmie pipe filling up the well from the
❑Aquifer Storage and Recovery ❑ Salinity Barrier bottom to the top. R� +%E_t �-
8.Certification: a"'�
❑ 6ghedmental Technology ❑Subsidence Control
��pJ2U��L 2 9 .2022
❑ Geothermal(dosed loop) ❑Geothermal(Heating/Cooling Retum) Date:0T/��y+"^"an prccaas"Una
❑Tracer ❑Other(e)plain) gym: aW 3OG
❑ Storrnaeter Drainage By signing this form,I hereby certify that the well(s)was(were) T
abandoned in accordance with 15A NCAC 02C.0100 or 2C 0200 Well
4.Date Well(s)abandoned 07/19/2022 Construction Standards and that a copy of this record has been
provided to the well owner.
5a.Well location 9.Site diagram or additional well details:
Facility OwmerName:Grocery bag Otgo Facility ID:00-0-0000032284 You may use the back of this page to provide additional well site details
Physical Address,aty,State,Zip:4879 MAy42 or well abandonment details.You may also attach additional pages if
County:Johnston Parcel ID:106 necessary
5b.Latitude and longitude in degrees/rrinutes/seconds or 10.SUBMITTAL INSTRUCTIONS
decimal degrees:
(If well field,one Iattlong is sufficient) 10a.For All Wells:Submit this form within 30 days of completion of
well abandonment to the following:
Longitude:78.344421 Latitude:35.653919
Division of Water Resources,Information Processing Unit,1617
CONSTRUCTION DETAILS OF WELLS)BEING ABANDONED Mail Service Center,Raleigh,NC 27699-1617
Attach well construction record(s)if available.For multiple injection or
non water supply wells ONLY with same construction abandonment. 10b.For Injection Wells:In addition to sending the form to the
you can submit one form. address in 10a 30 days of completion of well above,also submit one
6a.Well IDM DW-1 copy of this form within abandonment to the following
Division of Water Resources,Underground Injection Control
6b.Total well Depth(ft):39.5 Prograrn,1636 Mail Service C inter,Raleigh,NC 27699-1636
6c.Borehole diameter:2 10c.For Water Supply 8r Injection Wells:In addition to sending the
form to the address(es)above,also submit one copy of this form within
6d.Water level below ground surface:5.3 30 days of completion of well abandonment to the county health
6e.Outer casing length(if known):19.5 department of the county where abandoned
6f.Inner casing length(if known):
6a.Screen length(if known):10.00
Form GW-30 North Carolina Department of Environment and Natural Resoumes-Division of Water Resources Reused August 2013
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WELL ABANDONMENT RECORD For Internal Use ONLY
This form can be used for single and multiple wells
f
1.Well Contractor Information WELL ABANDONMENT DETAILS
Well Contractor Name:Gary A Fischer 7a.Number of wells being abandoned:1
Well Contractor Certification:3339
Company Name:Md-Atlantic Assoc. For multiple injection or non water'supply wells ONLY with same
contruction abandonment.you can submit one form.
2.Well Construction Permit#: 7b.Approximate volume of water remaining in well(s):0.00(gal.)
3.Well use(check well use)
Water Supply Well: FOR WATER SUPPLY WELLS ONLY
❑Agricultural ❑Municipal/Public 7c.Type of disinfectant used:
❑Geothermal ❑ Residential Water Supply(single) 7d.Amont of disinfectant used r
❑Industrial/Cortmrerdal ❑ Residential Nkter Supply(shared)
❑Irrigation 7e.Sealing materials used:Neat Cement Grout
Non Water Supply Well: 7f.For each material selected above,provide amount of material
used:4.0 gals.Water 15 lbs.Type 1 Portland cement 1 lb.Powdered
Monitoring ❑ Recovery bentonite
Injection Well: 7g.Provide a brief description of the abandonment procedure:
❑Aquifer Recharge ❑ Groundwater Remediation Put a 1"pvc tremmie pipe down the well to the bottom.Poured neat
cement thru a funnel down the tremmie pipe filling up the well from the
❑Aquifer Storage and Recovery ❑ Salinity Barrier bottom to the top.
ElExperimental Technology ❑Subsidence Control 8.Certification: RECEIVED
❑Geothermal(dosed loop) ❑ Geothermal(Fiaating/Cooling Return) Date:07/19/2022 JUL 2 9 2022
El k koRalion 113mc a wing UnO
Tracer ❑Other(erglain) M10180c,
❑Stom otert]ainage By signing this form,I hereby certify that the well(s)was(were)
abandoned in accordance with 15A NCAC 02C.0100 or 2C 0200 Well
4.Date Well(s)abandoned 07/19/2022 Construction Standards and that a copy of this record has been
provided to the well owner.
5a.Well location 9.Site diagram or additional well details:
Facility CunerName:Grocery bag atgo Facility ID:00-0-0000032284 You may use the back of this pagelto provide additional well site details
Physical Address,City,Slate,Zip:4879 NC Fky 42 or well abandonment details.You may also attach additional pages if
County:Jonston Parcel ID:106 necessary
5b.Latitude and longitude in degrees/rrinutes/seconds or decimal degrees: 10.SUBMITTAL INSTRUCTIONS
(If well field,one latAong is sufficient) 10a.For All Wells:Submit this form within 30 days of completion of
well abandonment to the following:
Longitude:-78.344"0 Latitude:35.653930
Division of Water Resources,Information Processing Unit,1617
CONSTRUCTION DETAILS OF W'ELL(S)BEING ABANDONED Mail Service Center,Raleigh,NC 27699-1617
Attach well construction record(s)if available.For multiple injection or
non water supply wells ONLY with same construction abandonment. 10b.For Injection Wells:In addition to sending the form to the
you can submit one form. address in 10a 30 days of completion of well above,also submit one
copy of this form within abandonment to the following
6a.Well ID#:MW-7
Division of Water Resources,Underground Injection Control
6b.Total well Depth(ft):13 Program 1636 Mail Service Center,Raleigh,NC 276994636
6c.Borehole diameter:2 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
6d.Water level below ground surface:3.80 30 days of completion of well abandonment to the county health
6e.Outer casing length(if known):5.00 department of the county where abandoned
6f.Inner casing length(if known):
6a.Screen length(if known):8.00
Form GW30 North Carolina Department of Environment and Natural Resoumes-Division of Water Resources Reused August 2013
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