Granville_Well Abandonment_20221014 (2)

WELL ABANDONMENT RECORD For Internal Use ONLY:
4
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-hoop 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
4309-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.25 (gal.)
r,
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name �•
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0501081
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7c.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout i s Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: = ---- ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips - 50 lbS
❑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(Heating/Cooling Return) ❑Other(explain under 7g) Gravity pour bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 9/13/22
5a.Well location: y �,� x V 11 r
Kenneth J. Ferrell Jack's Best Buy Incident No.39227
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: O C T `i ZO22
318 Central Avenue, Butner, NC 27509
Pmc ��«�Uni1
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville 11890 By signing this form,I hereby certify that the ivell(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 ivell owner.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f I
(ifwell field,one lat/Iong is sufficient) 9.Site diagram or additional well details:
36.13455 N 78.75870 �, 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 WE,LL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.Pormultiple injection ornon-watersupply 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 IDS: MW-8 abandonment to the following:
k
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 30 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Injection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: tn.
$ 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: 12 (ft) Division of Water Resources,U i nderground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
10 (ft.) 10c.For Water Supply&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 coutity health department of the county where
6E Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): 20
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABANDONMENT RECORD For Internal Use ONLY:
RECEIVED
1.Well Contractor Information: y WELL ABANDONMENT DETAILS
Steven R. Gerrald OCT
14 2022 7a.For Geoprobe/DPT or Closed-L I oo p 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
4309-B IBC DEQ/DWfI� wells abandoned:t
NC Well Contractor Certification Number Central Office _ 7b.Approximate volume of water re maining in well(s): 1'6 (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0501081
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ii known
7d.Amount of disinfectant used: •
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑MunicipaUPublic ❑ Neat Cement Grout I e Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout I ❑ Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: — — ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 711 For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips - 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stormwater Drainage f
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
Gravity pour bentonite Chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 9/13/22
Sa.Well location: 1 U�
Granville County Jack's Best Buy Incident No.39227 Facility/Owner Name Facility ID#(if applicable) 8.Certification: O C T 1 f 2022
I
313 Central Avenue, Butner, NC 27509 unt
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville 26270
By signing this form, I hereby certify that the ivell(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 be`n provided to the well owner.
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.13433 N 78.75903 W You may use the back of this page�o 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 well construction record(s)ifavailable.For multiple injection 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 ID#: MW-9 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (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: 10 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
I
6e.Outer casing length(if known): (ft.)
10 10c.For Water Supply&Iniection 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 I health department of the county where
6f.Inner casing/tubing length(if known): NA (ft) abandoned. If
6g.Screen length(if known): 1 (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

i
WELL ABAND0NMEN1A1--&WD For Internal Use ONLY:
ryryC�+ y 4 ZOZ2
1.Well Contractor Information: &Jl.T 1 WELL ABANDONMENT DETAIL Si
Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-LIoo;p Geothermal Wells having the same
Well Contractor Name(or well owner personally abate r property) well construction/depth,only 1 GW-30 is needed. Indicate TOTAL NUMBER of
Men lC� wells abandoned:t 1
4309-B I
NC Well Contractor Certification Number 7b.Approximate volume of water rem
aining in well(s): 1.15_(gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name i!
WM0501081 7c.Type of disinfectant used: :,
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County,State,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 I 11 Bentonite Chips or Pellets
❑Geothermal(HeatingtCooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout f ❑Dry Clay
❑Industrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑hTi ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
CMonitoring ❑Recovery
Injection Well: 7E For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips - 50 ibs
❑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(Heating/Cooling Return) ❑Other(explain under 7g) Gravity pour bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 9/13/22 1-
i'
5a.Well location: I •^rs
:.
Zachary Byrd
Jack's Best Buy Incident No.39227 •-v >-..i
Facility/Owner Name Facility ID9(ifapplicable) 8.Certification: OCT 20Z2
325 Central Avenue, Butner, NC 27509 ; 1.. II LlJ
Physical Address,City,and v.�:,,,,;J t
Y b'. P Signature of Certified Well Contractor or Well Owner vt�d paz�eQ�
Granville 7670
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.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I i
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
36.13469 N 78.75985
abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
IOa. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-11 abandonment to the following:
i•
Division of Water Resources,Information Processing Unit,
6b.Total well depth 20 (ft) 1617 Mail Service Center,Raleigh,NC 27699-1617
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in,) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
I ;
6d.Water level below ground surface: 13 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Ceuter,Raleigh,NC 27699-1636
10 10c.For Water Sunaly&Iniectio i Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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): 10 (ft.)
I
i
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

is
WELL ABANDONMENT RECORD For Internal Use ONLY:
i
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-I1oop 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
4309-B wells abandoned:
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): 1.25 (gal)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#:
WM0501081
List all applicable well construction permits(i.e.ULC,County,State,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 ❑MunicipaUPublic ❑ Neat Cement Grout I 11 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)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips - 50 Ibs
❑Aquifer Storage and Recovery ❑Salinity Barrier
i
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control i'
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I.❑Geothermal(HeatinglCoolingRetum) ❑Other(explain under 7g) Gravity pour bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 9/13/22
5a.Well location: OCT7
n22
Zachary Byrd Jack's Best Buy Incident No.39227 1 f 6t
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: -.• cgsnUnill
325 Central Avenue, Butner, NC 27509
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville 7670
By signing this form, 1 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: I
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.13501 N 78.75960 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 well construction records)tfavailable.For multiple injection or non-water supply wells
ONLY with the same constuctionlabandonment,you can submit one form:
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-12 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 20 (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
1` .
10b.For Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 8 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following: j
6d.Water level below ground surface: 12 (ft-) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10 10c.For Water Su
6e.Outer casing length(if known): (ft.) oaly&Iniection 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
6L Inner casing/tubing length(if known): NA (ft) abandoned.
6g.Screen length(if known): 10 (ft.)
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

}
WELL ABANDONMENT RECORD For Internal Use ONLY:
RECEIVED I
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven R. Gerrald 14 2022 7a.For Geoprobe/DPT or Closed-IJo fp 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
wells abandoned:t 1 !
4309-B NC©EQ/DVV� I
NC Well Contractor Certification Number Central Office 7b.Approximate volume of water remaining in well(s). 0'8 (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used:
2.Well Construction Permit#: WM0501114
I
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifknown
7d.Amount of disinfectant used: '
3.Well use(check well use):
i
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑ Neat Cement Grout i e 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 f ❑Drill Cuttings
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: - ❑ Bentonite Slurry ❑ Other(explain under 7g)
MMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑GroundwaterRemediation Bentonite Chips - 50 Ibs
❑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 I '
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 7g) Gravity pour bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 9/13/22
I
5a.Well location:
Kenneth J. Ferrell Jack's Best Buy Incident No.39227 O C T
2022
Facility/Owner Name Facility ID#(if applicable) 8.Certification:
I
318 Central Avenue, Butner, NC 27509 Info Ml1&iD m., ys,; ur,,.l
;;�r.-.
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner max.B-Date
Granville 11890
By signing this form,I hereby certify that the ipell(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 of this record has been provided to the spell owner.
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.13543 N 78.75913 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
Auach well construction records)ifavailable.For multiple ityectionornon-water supply wells
ONLY with the saute constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#. M W-14 abandonment to the following:
Division of Water Resources,Information Processing Unit,
20 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Injection Wells: In addition to sending the form to the address in 10a
Gc.Borehole diameter:
$ (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: 14 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
10 10c.For Water Suauly&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) 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]mown): NA (ft) abandoned.
6g.Screen length(if known): 10 (ft.) '
I
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i

I
I '
WELL ABANDONMEN AE RD For Internal Use ONLY: p
1.Well Contractor Information: WELL� 2022 ABANDONMENT DETAILS
Steven R. Gerrald
t1rT i
- 7a.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same
Well Contractor Name(or well owner personally ab&d�nip&yvpl]q� r property) well construction/depth only 1 GW-30 is needed. Indicate TOTAL NUMBER of
4309-B 66✓✓UUCCaI,+ll/v Central Office) wells abandoned:1 1
NC Well Contractor Certification Number 7b.Approximate volume of water rem aining in well(s): 0'8 (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name i
7c.Type of disinfectant used:
2.Well Construction Permit#:
WMO5O1114
List all applicable well construction permits(i.e.UIC,County,State,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 a 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
RMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips - 50 Ibs
❑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 I„
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g) Gravity pour bentonite chips monitored using weighted
tape. Distilled water added for hydration above water table.
9/13/22
4.Date well(s)abandoned:
5a.Well location:
Kenneth J. Ferrell Jack's Best Buy Incident No.39227 OCT I
- 2022
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification:
Uril
318 Central Avenue, Butner, NC 27509
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
Granville 11890
By signing this form, I hereby certify that the ivell(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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well details:
36.13536 N 78.75884 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 ifnecessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction records)ifavailable.For multiple h jection 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 ID#: MW-15 abandonment to the following:
Division of Water Resources,Information Processing Unit,
20 1617 Mail Service Center,Raleigh,NC 27699-1617
6b.Total well depth: (ft.)
10b.For Injection Wells: In addition to sending the form to the address.in 10a
6c.Borehole diameter: 8 (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: 15 (ft) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
6e.Outer casing length(if known):
10 10c.For Water Supply&Iniectio 1 Wells: In addition to sending the form to the
(ft.)
address(es)above,also submit one copy of this form within 30 days of completion
of well abandonment to the counity I health department of the county where
6f.Inner casing/tubing length(if known): NA (ft.) abandoned.
6g.Screen length(if known): 10 (ft.)
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
i .

l
I
WELL ABANDONMENT RECORD For Internal Use ONLY:
I
i
1.Well Contractor Information: WELL ABANDONMENT DETAI fLSI
Steven R. Gerrald 7a.For Geoprobe/DPT or Closed-
190 Ip 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
4309-B wells abandoned:-'
NC Well Contractor Certification Number 7b.Approximate volume of water rle I aining in well(s): 5.75 (gal.)
I
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7c.Type of disinfectant used: I
2.Well Construction Permit#: WM0501114
List all applicable well construction pennits(i.e.UIC,County,State,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 11 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
❑Irri ation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
eMonitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
❑Aquifer Recharge ❑Groundwater Remediation Bentonite Chips - 100 lbS
❑Aquifer Storage and Recovery ❑Salinity Barrier
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❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
7g.Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer I '
Gravity pour bentonite chips monitored using weighted
El Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 9/13/22
5a.Well location: --
Kenneth J. Ferrell Jack's Best Buy Incident No.39227 1 n
Facility/Owner Name Facility ID#(ifapplicable) 8.Certification: OCTI
318 Central Avenue Butner NC 27509 1n€:)r ra;ic:I Pr-;,_
e wsg.:3 Unil
Physical Address,City,and Zip Signature of Certified Well Contractor or Well bwner �'+9 Date
Granville 11890
By signing this form,I hereby certify that the ivell(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:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well detl ils:
36.13557 N 78.75874 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 well construction record(s)ifavailable.For multiple injection ornon-watersupply 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 ID#: MW-16 abandonment to the following:
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 5O (ft.) 1617 Mail Service CcInter,Raleigh,NC 27699-1617
10b.For.Iniection Wells: In addition to sending the form to the address in 10a
6c.Borehole diameter: 4 (in.) above,also submit one copy of thi%form within 30 days of completion of well
abandonment to the following:
6d.Water level below ground surface: 14 (ft.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
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6e.Outer casing length(if known): (ft.)
10c.For Water Supply&Iniectiori 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
611 Inner casing/tubing length(if known): 35 (ft.) abandoned.
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6g.Screen length(if known): 15
Form GW-30 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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