Nash_Well Abandonment_20221007

WELL ABANDONMENT RECORD ForintemaluseoNLy: -
0
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Wes Sorrells
7a.For Geoprobe/DPT or ClosediLoop Geothtr-r0.A1!ehs'lid�i 'fhe same
Well Contractor Name(or well owner personally abandoning well on bislher property) well construction/depth,only I GW-30 is needed'.'iidiciit:TOTAL NUMBER of
3577 wells abandoned:a
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
Terraquest Environmental Consultants, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
2.Well Construction Permit#:
WI0501108 7c.Type of disinfectant used:
List all applicable well construction permits(i.e.UIC,County,Sate,Variance,etc)ifknown
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 S Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑Drill Cuttings
❑lrri ation ❑ Specialty Grout ❑Gravel
Non-Water Supply Well: ❑Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge N Groundwater Remediation less than 1/4 50# bag
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heatin Cooling Return) ❑Other(explain under 7g)
2.25" borehole filled with bentonite chips
4.Date well(s)abandoned: 5/3,25/22
5a.Well location:
L&L Food Store#5 00-0-0000022386
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
109 W Nash St, Spring Hope, NC (,lJ�ay �e� 10-3-22
Physical Address,City,and Zip Signature of Certified 6611 Contractor or Well Owner Date
Nash 276962957763
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
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:
35.944339 N -78.112804 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 WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach wellconstruenon record(s)ifavailable.For multiple injection or non-watersupply wells
ONLY with the some construc#oniabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: I NJ 1-8 abandonment to the following:
J'Dmsiio'n,ofWat Re sourcesdinf or=mdo P o ess tn gUili4-„
160 MA Sd 246RCen�t r,Raleigh,N 227699% 7"
6b.Total well depth: (ft) —
10b.For Infection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 2.25 (in.) above, also submit one copy of this form within 30 days of completion of well
abandonment to the following: i
20 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Centler,Raleigh,NC 27699-1636
6e.Outer casing length(if known): (ft.) 10c.For Water Sunnily&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
6E Inner casing/tubing length(if known): (ft.) abandoned.
i
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources { Revised 2-22-2016
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