WQ0003626_Well Abandonment and Construction_20131021

Barber, Jim
From: Jamie Collins<[e-mail]>
Sent: Wednesday, September 18, 2013 1:52 PM
To: Barber, Jim
Subject: abandonment
Attachments: MW # 3 well abandonment form.pdf
Don't know if Grady Dobson sent this
Jamie Collins
Campbell Soup Supply Company L.L.C.
Environmental & Facilities Manager
2120 N C Hwy 71 North I Maxton, NC 28364
I`Z(910) 844-1654 1 [L;[phone] I mobile [phone]
1 jamie [e-mail]
First !.,Our
futurr
SWOOP
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1

1. WELL CONTRACTOR:
Grady Dobson
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 40766
6. WELL DETAILS:
Well Contractor (Individual) Name
Environmental Hydrogeological Consultants, Inc.
Welt Contractor Company Name
207 West Fourth Avenue
Street Address
Red Sprimgs
NC
28377
City or Town
( 910 ) 844-4456
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) MW-3
State
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable) WQ0003626
Zip Code
WELL USE (Check applicable use)" Monitoring Residential
❑ Municipal/Public f 1 Industrial/Commercial Agricultural
❑ Recovery 'LJ Injection Irrigation
Other (list use)
3. WELL LOCATION:
COUNTY Robeson QUADRANGLE NAME Maxton,NC
NEAREST TOWN: Maxton,NC
1313 Modest Road 28364
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
Slope IJ Valley Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 34 . 48 13.0000 ^ DMS OR 3X.XXXXXXXXmD
LONGITUDE 79 ^ 18 48.0000 " DMS OR 7X.XXXXXXXXa4D
Latitude/longitude source: EitPS []Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY - The name of the business where the well is located. Complete 4a ;
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY Campbell Soup Supply Company
STREET ADDRESS 2120 NC 71 HWY North
Maxton
NC 28364
City or Town State
4b. CONTACT PERSON/WELL OWNER:
NAME Jamie Collins -Environmental Manager
Zip Code
STREET ADDRESS 2120 NC71 HWY North
a.Total Depth 24
ft. Diameter:4 in.
b. Water Level (Below Measuring Point): ft.
Measuring point is 3 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
7. DISINFECTION: 2 gal
Length Diameter
19
19
ft.
ft.
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
4
Neat Cement Sand Cement
Cement 50 Ib. Cement
Water
Bentonite
4
5 gal. Water
Bentonite 250 Ib.
Type: Cl Slurry di Pellets
Water gal.
Ib.
qal.
Other
Type material
Amount
in.
in.
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
Fntire WRIT removad an then rhlnrinateri with 2 gal of 55% 7S%
calcium hypochlorite solution.Bentonite was poured Ca. a bag/2min
and hydrated with water. Capped with Class I concrete mixture
10, WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED August 14,2013
i 00 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STAN DAROS, AND THAT A COPY OF
THIS RECOR ; BEE a PIOVIDED FO`%}1E WELL OWNER.
SIGNA ' E OF CERT - WEL CONTRACTOR ///
AT
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual wtersonalhabandons his/her residential well
in accordance with 15A NCAC 2C 0113.)
Grady Dobson
PRINTED NAME OF PERSON ABANDONING THE WE LL
Submit a copy to the owner and the original to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-1617, Phone : [phone]
Form GW-30
Rev. 5/10

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1 i ^ V))C. V r 11.
1. Well Contractor Information:
Grady Dobson
Well Contractor Name
4076B
NC Well Contractor Certification Number
Environmental Hydrogeological Consultants,lnc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
▪ Monitoring ❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
DTracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 O/21 /13 Well ID# 3A
5a. Well Location:
Campbell Soup Supply Co.
Facility/Owner Name
Facility ID# (if applicable)
1313 Modest Road,Maxton,NC 28364
Physical Address, City, and Zip
Robeson
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34°48'23" N 79°18'48"
w
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
If this is a repair, /1!1 out known well construction information and explain the nature of the
repair under .21 remarks section or on the back of this form.
8. Number of wells constructed: one
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
14. WATER ZONES
FROM
TO
DESCRIPTION
ft
ft.
ft
ft
1S. OUTER
CASING (for
multi -cased wells) OR LINER (if ap Geable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft
20 ft
in-
0.01
ft.
ft.
is
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
1 ft
4 ft
Bentonite
0 ft
4 ft
concrete
ft
ft
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft.
20 ft
ft.
ft
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain sift, etc)
0 ft
2 ft
Organic material
2 ft
5 ft
Brown Coarse sand
5 ft.
10 ft
yellow coarse sand
10 ft
15 ft.
Orange coarse sand
15ft.
20 ft
,Y s
ft.
ft
tED
ft.
ft
T y�
21. REMARKS Of. 12 5 l 11 f 3
arA ' RAgF NION
C-Uwrr
9. Total well depth below land surface: 20 (ft.)
For multiple wells list all depths if dzerent (example- 3@200' and 2@100')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "- "
11. Borehole diameter: 2
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-1
22. Certification:
Signature of CertifieidrAfell Contractor
/cftq, 3
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & 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 construction to the county health department of the county
where constructed.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 201;