Durham_Well Abandonment_20220808

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Thomas Will
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
2700bwells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.)
East Coast Environmental PA FOR WATER SUPPLY WELLS ONLY:
Company Name chlorox tool shock
7c.Type of disinfectant used: P
2.Well Construction Permit#: NA
List all applicable nwil construction permits f.e.UIC,County,State.Variance,etc.)ifknown
7d.Amount of disinfectant used: 6 OZ
3.Well use(check well use):
Water Supply Well: 7e.Seating materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout a Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial RResidential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑hri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: O Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite pellets 800 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer
7g.Provide a brief description of the abandonment procedure:
s❑Geothermal(Heating/Cooling Return) chi poured in tots of well until) ❑Other(explain under 7g) P P p
well was full. 20 gallons of hydration water
4.Date wells)abandoned: 8�5�22 was added while chips were bing placed in well
52.Well location:
Pulte Homes NA Facility/Owner Name Facility ID#(ifapplicable) It.C77�
1101 Olive Branch Road 8/5/22
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Durham 231680
By signing this form,I hereby certify that the well(s) was(were)abandoned in
County Parcel Identification No.(PIN) accordance with 15A NCAC 02C.0100'or 2C.0200 Well Construction Standards
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details: ID
�'
35 57' 27.10tr N -78 46r 22.22 W You may use the back of this page to provide additiPn'Wi
abandonment details. You may also attach additional pages ifnecessary.CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS AUG 0 8 2022
Attach well construction record(s)ifavailable. For multiple affection or non-water supply wells
ONLY with the same constructions/abandonment,you can submit oneform.
10a. For All Wells: Submit this form within
6a.Well ID#: 1 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 55 (ft,) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 6 (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• 55 A) 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 Supply&Iniection Welts: 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): (ft.) abandoned.
6g.Screen length(if known): na (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016