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Home My WebLink AboutWake_Well Abandonment_20221007 f WELL ABANDONMENT RECORD For Internal Use ONLY: O C T 0 i 2022 1.Well Contractor Information: WELL ABANDONMENT DETAItiS David E. Meyer ln�,f;;: �� f ,:. ,.: :._, un'. Y 7a.For Geoprobe/DPT or Closed-Loop GeotlRioiZWQ` having the same Well Contractor Name(or well owner personally abandoning well on his/her property) well construction/depth,only I GW-30 is needed. Indicate TOTAL NUMBER of wells abandoned: 2527-A NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 (gal.) Protocol Sampling Service, Inc. FOR WATER SUPPLY WELLS OONLLY: Company Name 7c.Type of disinfectant used: '�n 2.Well Construction Permit#: GW-088576-2022 ` Lit all applicahle well construction permits(i.e.U/C,CounlY,Stale,Variance,etc.)ifknown 6' oz. 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 a Neat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑Industrial/Commercial AResidential Water Supply(shared) ❑Concrete Grout ❑ Drill Cuttings ❑lni ation ❑ 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: ❑Aquifer Recharge ❑Groundwater Remediation 250 gallons ❑Aquifer Storage and Recovery ❑Salinity Barrier []Aquifer Test ❑Stormwatcr Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer Well sounded, found free of obstructions ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) pump and drop pipe removed, filled with neat cement grout 4.Date well(s)abandoned: September 27,2022 top 4' casing removed, backfilled to original grade 5a.Well location: and compacted. SASA Development Inc. na Facility/Owner Name Facility ID#(if applicable) S-Certification: 1709 Clifford Road Garner, NC 27529 9/27/2022 Physical Address,City,and Zip Signature of Certified II Contractor or Well Owner Date Wake 1629059085 Br signing this form, 1 herebv certyy 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 Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy qf this record has been provided to the well owner. (it"well field,one lai/long is sufficient) a 9.Site diagram or additional well details: 35 39' 32.460 N 78 35' 33.874" 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 Atlnchirellconstr•uctionrec•ord(s)ifavailable. Fot•nndlipleinjecvionot•non-v%,alersrepph-,tells ONLY with the.sante c•atstntcviatt/abat,domnent,rou cull submir one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: 2 abandonment to the following: Division of Water Resources,Information Processing Unit, 80 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Total well depth: 10b.For Infection Wells: In addition to sending the form to the address in 10a 6e.Borehole diameter: 6.5 (in.) above, also submit one copy of this1fonm within 30 days of completion of well abandonment to the following: 33.0 Division of Water Resources,Underground Injection Control Program, 6d.Water level below ground surface: (ft.) 1636 Mail:Service Center,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 36 (ft.) 10c.For Water Supply&IniectioniWells: 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 6f.Inner casing/tubing length(if known): na (g,) abandoned. 1f 6g.Screen length if known): n a (ft.) Form GW-30 North Carolina Department of Environmental Quality-Division or Water Resources Revised 2-22-2016 i OCT 0 i 2022 WELL ABANDONMENT RECORD For Intemal Use ONLY: I,,; , ; 9 Ur,;, 1.Well Contractor Information: WELL ABANDONMENT DETAIL'S David E. Meyer 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 I GW-30 is needed. Indicate TOTAL NUMBER of 2527-A wells abandoned: NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 0 -(gal.) Protocol Sampling Service, Inc. FOR WATER SUPPLY VVELLS 0 NLY: Company Name none -dry 2.Well Construction Permit#: GW-088576-2022 7c.Type of disinfectant used: List all applicable well construction pennfis(i.e.U/C,County,Stale,Variance,etc.)ifknown none 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) ®Residential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay ❑industrial/Commercial UResidential Water Supply(shared) ❑Concrete Grout ❑Drill Cuttings ❑irrigation ❑ Specialty Grout ❑Gravel Non-Water Supply Well: ❑ Bentonite Slurry S Other(explain under 7g) ' ❑Monitoring ❑Recovery Injection Well: 7f.For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑GroundwaterRemediation Process fill 4 yds. ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑Stomrwater Drainage ❑Experimental Technology ❑Subsidence Control 7g.Provide a brief description of the abandonment procedure: ❑Geothennal(Closed Loop) ❑Tracer ❑Geothennal(Heating/CoolingReturn) ❑Other(explain under 7g) Well sounded, found free of obstructions filled with process fill,top T casing removed, compacted 4.Date well(s)abandoned: September 27,2022 and brought to original grade 5a.Well location: SASA Development Inc. na Facility/Owner Name Facility ID#(if applicable) 8 C ffieation: 1709 Clifford Road Garner, NC 27529 9/27/2022 Physical Address,City,and Zip Signature of Certified Well Cl5ntractor or Well Owner Date Wake 1629059085 I By signing this Jorm. l herebv cerlyi,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 Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: and that a copy of this record has been provided to the well owner. (if well field,one lat/long is sufficient) ° 9.Site diagram or additional well details: 35°39' 31.674 N 78 35' 33.905" 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 u•ellconsiructionrecord(s)ifavailable. Formeltipleinjecliorrornon-nutersupplr,rells ONLY with the same constnrction%abandonmenr,you can subnrir one form. 10a. For All Wells: Submit this form within 30 days of completion of well 6a.Well ID#: 1 abandonment to the following: Division of Water Resources,Information Processing Unit, 30 1617 Mail Service Center,Raleigh,NC 27699-1617 6b.Total well depth: (ft.) 10b.For Infection Wells: In addition to sending the form to the address in 10a 6c.Borehole diameter. 24 (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: 0- dry (ft.) Division of Water Resources,Underground Injection Control Program, 1636 Mail Service Cent ter,Raleigh,NC 27699-1636 6e.Outer casing length(if known): 30 (ft•) 10c.For Water Sunply&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 county where 6f.Inner casing/tubing length(if known): na (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 . P