Durham_Well Abandonment_20220817

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Barry Norwood 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
4165 A wells abandoned:
40
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal)
NW Poole Well and Pump Co FOR WATER SUPPLY WELLS ONLY:
Company Name Granulated HTH
N/A 7e.Type of disinfectant used:
2.Well Construction Permit M
List all applicable well construction permits(i.e. UIC,County,State,Yarfance�eta)ifknown 1 lb.
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 ❑Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial 4❑Reuel Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings
❑Irri ation = e Specialty Grout s Gravel
Non-Water Supply Well:` ❑ Bentonite Slurry ❑Other(explain under 7g)
❑Monitoring "I very
Injection Well: ���nr�� 7£For each material selected above,provide amount of materials used:
❑Aquifer Recharge 1 ;�f:,i r r• c[2Z�roi#�davt[ter Remediation 0.5 yard of env. fill 20 bags of#3 gravel
❑Aquifer Storage and Recovery L7Salinity Barnes
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g provide a brief description of the abandonment procedure:
❑Geothemral(cl°sea Loop) ❑Traces Poured material in from the surface.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
4.Date well(s)abandoned: 07/11/22
Sa.Well location:
Scannell Properties
Facility/Owner Name Facility ID#(if applicable) Certification:
1130 Junction Rd. Durham NC 27704 07/12/22
Physical Address,City,and Zip Signature off
Contractor or Well Owner Date
Durham 0842-77-84-2768
By signing this form,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.
Sb.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:
36* 01' 04.84" N 78* 50' 21.44" 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 WELLS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable For multiple hg'ection or non-water supply 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 IDl#: abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 102 ap 1617 Mail Service Center,Raleigh,NC 27699-1617
lob.For ection 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: 75 (ft) Division of Water Resources,Underground Injection Control Prograrq
1636 Mail Service Center,Raleigh,NC 276994636
6e.Outer casing length(if known): (g,) 10c.For Water Sunnly&Injection Wells: In addition to sending the form to the
address(es)above,also submit one,copy of this fours within 30 days of completion
of well abandonment to the county health department of the county where
6E Inner casing/tubing length(if known): 64 (B) abandoned.
i
6g,Screen length(if known): (tl.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016