Durham_Well Abandonment_ (13)

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
2700b wells 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 chIlorox pool shock
7c.Type of disinfectant used: p
2.Well Construction Permit#: NA
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc)ifknowi,
7d.Amount of disinfectant used: V OZ
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
Olndustrial/Commercial @Residential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation O Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
OAquifer Recharge ❑GroundwaterRemediation Bentonite pellets 550 pounds
❑Aquifer Storage and Recovery ❑Salinity Barrier
OAquifer Test ❑Stormwater Drainage
OExperimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
OGeothermal(Closed Loop) ❑Tracer
OGeothermal Bentonite chips poured in top of well until
(Heatin Cooling Return) ❑Other(explain under 7g) p p
well was full. 10 gallons of hydration water
4.Date wells)abandoned: 8/5/22 was added while chips were bing placed in well
Sa.Well location:
Pulte Homes NA
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
1101 Olive Branch Road 8/5/22
Physical Address,City,and Zip Signature of Certified Well ontractor or Well Owner Date
Durham 231680
By signing this form, I hereby certify that the well(v) 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:
(if well field one lottlong is sufficient)
9.Site diagram or additional well details:
35 57' 25.57" N -78 46' 26.37" �, You may use the back of this page to"provide additional well site de tls
abandonment details. You may also attach addition[ i naP
CONSTRUCTION DETAILS OF WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple iryectionornon-watersupplywells
ONLY with the same corutnrction/abandonment,you can submit oneforn,. 10a. For All Wells: Submit this form within 30 days of completion ofwell
6a.Well ID#: 2 abandonment to the following: it orvr+ n Proc&zo Lg Lln�
MttQ/SQG
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 35 (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: 4 (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: 35 (fj) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): unknown (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
6L 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