Granville_Well Abandonment_ (22)

WELL ABANDONMENT RECORD For Internal Use ONLY:
1.Well Contractor Information: WELL ABANDONMENT DETAILS
Steven R. Gerrald 79.For Geoprobe/DPT or Closed-L!oop 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 i
4309-B i
NC Well Contractor Certification Number
7b.Approximate volume of water remaining in well(s): 2 (gal.)
Leaf Environmental & Engineering, P.C. FOR WATER SUPPLY WELLS ONLY:
Company Name
7e.Type of disinfectant used: NOVV�/
Ti 2022
2.Well Construction Permit#: N/A
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)ifktown Irgo/�'"On Prmase v UM
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
❑hrri 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 - 25 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 Gravity pour bentonite chips monitored using weighted
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 7g)
tape. Distilled water added for hydration above water table.
4.Date well(s)abandoned: 1 0/21/22
Sa.Well location:
Jacks Best Buy Jack's Best Buy Incident No.39227
Facility/Owner Name Facility ID#(if applicable) 8.Certifi ation:
315 Central Avenue, Butner, NC 27509
Physical Address,City,and Zip Sign'afure of ertified Well Contractor or'Well Owner Date
Granville
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.
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 9.Site diagram or additional well'details:
36.13454 N 78.75931 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 record(s)ifavailable.For multiple injection or non-water supply wells
ONLY with the same constructionlabandonment,you can submit one form.
10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#: MW-6 abandonment to the followin&
Division of Water Resources,Information Processing Unit,
6b.Total well depth: 15 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: 6 (in.) above,also submit one copy of this form within 30 days of completion of well
abandonment to the following:
10.8 Division of Water Resources,Underground Injection Control Program,
6d.Water level below ground surface: (ft.)
1636 Mail Service Center,Raleigh,NC 27699-1636
5 10c.For Water Supply&Iniection Wells: In addition to sending the form to the
6e.Outer casing length(if known): (ft.) address(es)above,also submit one dopy 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): NA (ft) abandoned.
4
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
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