Edgecombe_Well Abandonment_20220919 (2)

♦ ELL ABANDONMENTRECORD For Internal Ilse(7MY
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABA%IN)NyIENT DETAILS
COREY D. FUTRAL 7s.Number nl'we1Ls being abandoned: N/A
Well Contractor Name(or well owner personall}abadoning rsell on lusher property) Formrdople,ye,1... iwnvwer supply xrtA ONLY cone rbe.ame
rnvmrcrion a(uahxmrru m ran sv(wnr rurhrrx.
4330B
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in%elks): N/A (gal.)
CATLIN Engineers and Scientists FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used: N/A
2.Well Construction Permit N: N/A
Gsr all appLaaMe well pemma li r.Cowry,Sbre.Y one.Iryrennn.ea.)r,fkoown
7d.Amount of disinfectant used: N/A
3.Well use(check wed use):
Water Supply Wed: 7e.Sealing materials used(check all that apply):
OAgricultural ❑MunicipzFPubiic ❑Neat CemenlGmut I&Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay
Olndustrial/Cominereial ❑Residential Water Supply(shared) OConcrete Grout ❑Drill Cuttings
Mitigation ❑Specialty Grout OGovel
Non-Water Suppy Wed: ❑Bentonite Slum ❑Other(explain under 7g)
■Monitoring ❑Recovery
Injection Wed: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Pellets —20 lbs lbs.
OAquifer Stooge and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
OGeoOnertral(Closed Loop) ❑Tracer 7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Heating/Cooling Retum) OOdrer(explain under 7g) Pulled all well material out of ground and baekfilled with
hydrated bentonite pellets to e)dstin r de.
4.Date weds)abandoned: 9/7/2022 „t
Sa.Wed Location: Sr P
NCDEQ-LINDA BLALOCK NA L
Facility/Owner Name Facility 04(if applicable) 8.Certification: ?r�7
l7. .r..'t.: u
Unk
7995 NC-03, ROCKY MOUNT, ROCKY MOUNT, NC 27801
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
EDGECOMBE NA By signing thu form I herebv ceraft that the wells)was(were)abandoned in
County Parcel Identification No (PIN) accordance with 15A NCAC 02C.0100 or2C 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 laulong is sufficient) 9.Site diagram or additional well details:
35.855541 N -77.683141 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 WELLIS)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Atlarh well evnvnrlian rerord/s/ijavoilable Formu(ripteoyeaionor.w- rsryp(Y
wdl ONLYw/rh Jhe star mrvtrvv1,m ahmalorunem.vwu carr o hons t 'form 10a.For All Weds: Submit this form within 30 days of completion of well
6a.Wed IDp: TMW-03 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Infection W'elh: In addition to sending the form to the address in
6c.Borehole diameter: 2.26(in.) IOa 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: NM(ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(d known): N/A 10c.For Water Suooh&Infection 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
6f.Inner casing/tubing length(if known): 5(ft.) county%,here abandoned.
6g.Screen length(if known): 10(ft.)
SIGs ROJECfSV COEQ-SLP PROJECrS(ALL)_CDF I W3_NCDEQ SIP M&R GROCERY GPI
Adapter Jim NCDENR-DWR Furor GW-30 Noah Carolina Depvurwnt or En.00rvsrnt arM Natural Resources-I3irwm of W'atc Resourm Revived Augua 2013

' N
TMW-03 y
NC 43
MW-3
DISPENSER
FORMER ISLAND
1,000-GAL. UST i (� TMW-02
MW-8 ® MW-1
MW-8R
MW-5
FORMER- FORMER
550-GAL. USTS MW 4 500-GAL. UST
Li `1 i �• r TMW=01
MW 7R r t
AS Ts
MW 2 • WSW-1
LEGEND MW-6R /
® Temporary Monitoring i
Well (Type II) at
® Monitoring Well
(Type II)
• Abandoned Monitoring
Well (Type II)
® Inactive Non-Potable
Water Supply Well
❑ Approximate Location
of UST/AST System
❑ Parcel Boundary Maxar.Earths a dgraphics.and the GIS User Comm
und
NOTE:Well and tank locations were obtained from previous reports
prepared by other consultants and are approximate. 40 20 0 ao so
Feet
PNoiECr ME FIGURE
M&R GROCERY
CATLIN ROCKY MOUNT, NC SITE MAP
Engineers and Scientists
INLIOENi NO. AB NO WiE SOME PUWN BVICBY
5720 221043 SEPT 2022 AS SHOWN IGACI IQrIGSJO